{"hospital_name":"Ssm Health St. Agnes Hospital-Fond Du Lac","last_updated_on":"2026-04-01","version":"3.0.0","location_name":["Ssm Health St. Agnes Hospital-Fond Du Lac"],"hospital_address":["430 E Division St, Fond Du Lac, WI 54935"],"license_information":{"license_number":"520088","state":"WI"},"type_2_npi":["1598743726","1346228541","1538147749"],"attestation":{"attestation":"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"John Snodsmith "},"modifier_information":[{"description":"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","code":"TC","modifier_payer_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"DOC","plan_name":"Government","description":"The modified price is presented in the standard charge value."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","description":"The modified price is presented in the standard charge value."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."}]}],"standard_charge_information":[{"description":"Apply hand/wrist cast","code_information":[{"code":"29085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System Without Mcc","code_information":[{"code":"002","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62230.42,"maximum":233116.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":176742.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204437.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195700.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184708.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123709.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148299.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62230.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":233116.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154935.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":226069.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200232.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170690.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84633.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194627.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","code_information":[{"code":"003","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":116561.62,"maximum":436641.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":331049.44},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":382923.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":366559.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":345970.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231715.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":277774.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116561.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":436641.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":290203.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":423442.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375049.28},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":319715.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158523.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":364550.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":165983.3,"10th_percentile":165983.3,"90th_percentile":165983.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","code_information":[{"code":"004","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":76067.2,"maximum":284949.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":216040.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249893.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239213.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":225777.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151215.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181273.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76067.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":284949.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189384.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":276335.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":244754.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208643.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103451.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237902.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant With Mcc Or Intestinal Transplant","code_information":[{"code":"005","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56621.78,"maximum":212106.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":160812.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":186011.73},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178062.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168061.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112559.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134933.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56621.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":212106.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140971.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":205694.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182186.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":155307.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77005.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177086.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant Without Mcc","code_information":[{"code":"006","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25464.83,"maximum":95391.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72323.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83656.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80080.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75583.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50622.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60684.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25464.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95391.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63399.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92508.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81935.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69847.13},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34632.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79642.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lung Transplant","code_information":[{"code":"007","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71118.12,"maximum":266409.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":201984.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":233634.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":223649.95},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":211088.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141377.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169479.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71118.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":266409.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177063.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258356.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":228830.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195068.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96720.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":222424.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant","code_information":[{"code":"008","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30778.57,"maximum":115297.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87414.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101112.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96791.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91354.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61185.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73347.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30778.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":115297.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76629.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111811.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99033.28},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84422.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41858.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96260.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas Transplant","code_information":[{"code":"010","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39406.52,"maximum":147617.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111919.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129456.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123924.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116963.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78337.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93908.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39406.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":147617.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98110.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143155.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126794.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108087.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53592.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123245.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","code_information":[{"code":"011","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29952.08,"maximum":112200.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85067.6},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98397.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94192.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88901.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59542.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71377.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29952.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112200.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74571.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108809.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96373.95},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82155.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40734.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93676.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","code_information":[{"code":"012","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23152.84,"maximum":86730.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65756.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76060.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72810.32},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68720.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46026.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55174.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23152.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86730.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57643.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84109.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74496.72},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63505.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31487.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72411.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","code_information":[{"code":"013","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15825.87,"maximum":59283.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44947.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51990.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49768.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46973.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31460.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37714.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15825.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59283.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39401.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57491.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50921.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43408.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21523.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49495.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allogeneic Bone Marrow Transplant","code_information":[{"code":"014","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65998.24,"maximum":247230.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":187443.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216814.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207549.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195891.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131199.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157278.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65998.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":247230.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164316.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239757.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":212356.29},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181025.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89757.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":206411.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant With Cc/Mcc","code_information":[{"code":"016","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32563.9,"maximum":121984.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":92485.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106977.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102405.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96654.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64734.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77601.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32563.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":121984.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81074.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118297.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104777.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89319.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44286.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101844.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant Without Cc/Mcc","code_information":[{"code":"017","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29832.35,"maximum":111752.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84727.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98004.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93815.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88546.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59304.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71092.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29832.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111752.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74273.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108374.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95988.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81826.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40572.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93301.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","code_information":[{"code":"018","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":237145.34,"maximum":888350.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":673522.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":779060.89},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":745766.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":703879.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":471426.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565133.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237145.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":888350.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":590421.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":861496.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":763040.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":650462.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322517.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":741679.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","code_information":[{"code":"019","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39180.81,"maximum":146771.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111278.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128715.32},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123214.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116293.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77888.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93370.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39180.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":146771.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97548.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142335.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126068.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107468.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53285.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122539.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43212.79,"maximum":161875.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":122729.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141961.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135894.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128261.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85903.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102978.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43212.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":161875.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107587.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156982.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139041.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118527.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58769.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135149.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","code_information":[{"code":"021","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29071.76,"maximum":108903.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82567.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95505.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91423.93},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86288.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57792.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69279.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29071.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":108903.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72380.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105611.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93541.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79740.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39537.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90922.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","code_information":[{"code":"022","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17449.21,"maximum":65365.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49557.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57323.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54873.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51791.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34687.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41582.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17449.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65365.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43443.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63389.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56144.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47861.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23730.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54572.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","code_information":[{"code":"023","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31468.87,"maximum":117882.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":89375.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103380.34},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98962.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93403.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62557.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74992.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31468.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":117882.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78348.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114319.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101254.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86315.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42797.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98419.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63571.61,"10th_percentile":63571.61,"90th_percentile":63571.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","code_information":[{"code":"024","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21482.84,"maximum":80475.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":61013.9},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70574.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67558.51},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63763.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51195.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21482.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80475.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53485.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78042.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69123.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58924.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29216.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67188.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","code_information":[{"code":"025","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24968.94,"maximum":93534.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70914.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82027.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78521.51},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74111.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49636.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59502.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24968.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93534.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62165.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90706.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80340.19},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68486.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33957.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78091.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32677.04,"10th_percentile":32677.04,"90th_percentile":34652.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Cc","code_information":[{"code":"026","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17074.67,"maximum":63962.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48494.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56093.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53695.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50679.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33943.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40690.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17074.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":63962.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42510.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62028.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54939.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46833.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23221.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53401.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":47704.98,"10th_percentile":47704.98,"90th_percentile":47704.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23728.23,"10th_percentile":23728.23,"90th_percentile":23728.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","code_information":[{"code":"027","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13854.92,"maximum":51900.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39349.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45515.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43570.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41123.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27542.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33017.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13854.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51900.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34494.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50331.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44579.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38002.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18842.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43331.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":42381.89,"10th_percentile":42381.89,"90th_percentile":42381.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Spinal Procedures With Mcc","code_information":[{"code":"028","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32995.55,"maximum":123601.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93711.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108395.74},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103763.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97935.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65592.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78630.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32995.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":123601.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82149.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119865.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106166.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90503.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103194.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Cc Or Spinal Neurostimulators","code_information":[{"code":"029","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18735.35,"maximum":70182.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53210.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61548.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58918.33},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55609.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37244.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44647.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18735.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70182.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46645.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68061.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60282.97},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51388.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25480.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58595.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25996.94,"10th_percentile":25996.94,"90th_percentile":25996.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":56444.92,"10th_percentile":56444.92,"90th_percentile":56444.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":50061.82,"10th_percentile":50061.82,"90th_percentile":50061.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17212.43,"10th_percentile":17212.43,"90th_percentile":17212.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures Without Cc/Mcc","code_information":[{"code":"030","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12055.3,"maximum":45159.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34238.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39603.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37911.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35781.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23965.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28728.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12055.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45159.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30014.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43794.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38789.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33066.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16395.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37703.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17212.43,"10th_percentile":17212.43,"90th_percentile":17212.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Mcc","code_information":[{"code":"031","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24605.39,"maximum":92172.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69882.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80832.7},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77378.24},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73032.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48913.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58636.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24605.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":92172.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61260.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89385.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79170.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67489.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33463.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76954.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Cc","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11702.73,"maximum":43838.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33237.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38445.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36802.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34735.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23264.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11702.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43838.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29136.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42513.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37654.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32099.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15915.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36600.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16551.57,"10th_percentile":16551.57,"90th_percentile":16551.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures Without Cc/Mcc","code_information":[{"code":"033","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9132.08,"maximum":34208.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25936.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30000.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28718.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27105.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18153.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21762.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9132.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34208.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22736.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33174.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29383.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25048.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12419.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28560.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21256.58,"maximum":79627.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60371.31},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69831.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66846.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63092.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42256.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50655.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21256.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79627.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52922.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77220.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68395.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58304.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28908.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66480.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Cc","code_information":[{"code":"035","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13127.82,"maximum":49177.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37284.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43127.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41283.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38965.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26097.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31284.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49177.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32684.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47690.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42240.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36008.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17853.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41057.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17623.36,"10th_percentile":17623.36,"90th_percentile":17623.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10669.2,"maximum":39967.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30301.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35050.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33552.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31667.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21209.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25425.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10669.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39967.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38758.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34329.28},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29264.4},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14510.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33368.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14203.28,"10th_percentile":14203.28,"90th_percentile":14203.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Mcc","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18079.1,"maximum":67724.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51346.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59392.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56854.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53661.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35939.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43083.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18079.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67724.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45011.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65677.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58171.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49588.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24587.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56542.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8910.77,"maximum":33379.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25307.69},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29273.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28022.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26448.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17713.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21234.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8910.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33379.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22185.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32370.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28671.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24441.22},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12118.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27868.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10836.69,"10th_percentile":10836.69,"90th_percentile":10836.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15095.67,"10th_percentile":15095.67,"90th_percentile":15095.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14826.17,"10th_percentile":14826.17,"90th_percentile":14826.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8824.03,"10th_percentile":8824.03,"90th_percentile":8824.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6455.44,"maximum":24182.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18334.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21207.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20300.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19160.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12832.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6455.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24182.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16072.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23451.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20771.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.56},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8779.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20189.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8961.93,"10th_percentile":8766.56,"90th_percentile":10730.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":23414.89,"10th_percentile":23414.89,"90th_percentile":23414.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8823.03,"10th_percentile":8823.03,"90th_percentile":8823.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21204.4,"maximum":79432.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60223.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69659.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66682.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62937.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42152.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50531.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21204.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79432.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52792.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77030.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68227.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58161.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28837.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66317.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12074.52,"maximum":45231.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34293.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39666.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37971.55},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35838.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24003.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28774.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12074.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45231.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30061.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43864.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38851.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33119.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16421.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37763.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":59948.66,"10th_percentile":59948.66,"90th_percentile":59948.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16047.2,"10th_percentile":16047.2,"90th_percentile":16047.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9487.94,"maximum":35542.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26946.94},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31169.44},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29837.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28161.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18861.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22610.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9487.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35542.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23622.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34467.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30528.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26024.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12903.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29673.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries With Cc/Mcc","code_information":[{"code":"052","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9947.05,"maximum":37261.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28250.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32677.66},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31281.15},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29524.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23704.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9947.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37261.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24765.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36135.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27283.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13527.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31109.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":2313.69,"10th_percentile":2313.69,"90th_percentile":2313.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries Without Cc/Mcc","code_information":[{"code":"053","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5377.43,"maximum":20143.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15272.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17665.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16910.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15960.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10689.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12814.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5377.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20143.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19535.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17302.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14749.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7313.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16818.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8385.22,"maximum":31411.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23815.06},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27546.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26369.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24888.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16669.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19982.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8385.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31411.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20876.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30461.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26980.32},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22999.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11403.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26225.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10795.08,"10th_percentile":10795.08,"90th_percentile":10795.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11910.22,"10th_percentile":11910.22,"90th_percentile":11910.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11539.02,"10th_percentile":11539.02,"90th_percentile":11539.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms Without Mcc","code_information":[{"code":"055","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5599.3,"maximum":20975.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15902.7},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18394.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16619.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11130.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13343.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5599.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20975.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13940.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20341.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18016.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15358.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7615.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6537.43,"10th_percentile":6537.43,"90th_percentile":6537.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12757.68,"maximum":47790.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36233.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41911.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40119.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37866.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25361.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30402.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12757.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47790.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31762.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46345.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41049.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34992.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17350.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39900.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32437.93,"10th_percentile":32437.93,"90th_percentile":36410.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":108927.9,"10th_percentile":108927.9,"90th_percentile":108927.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16462.19,"10th_percentile":2493.82,"90th_percentile":21322.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7115.0,"maximum":26652.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20207.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23373.92},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22375.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21118.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16955.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7115.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26652.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17714.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25847.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19515.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9676.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22252.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6685.24,"10th_percentile":6685.24,"90th_percentile":6685.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20883.67,"10th_percentile":20883.67,"90th_percentile":36098.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10369.04,"10th_percentile":10205.52,"90th_percentile":19896.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6685.24,"10th_percentile":6685.24,"90th_percentile":6685.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"16","median_amount":16349.87,"10th_percentile":10356.65,"90th_percentile":35744.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":81090.0,"10th_percentile":81090.0,"90th_percentile":81090.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":9455.66,"10th_percentile":343.76,"90th_percentile":36098.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8963.55,"10th_percentile":8963.55,"90th_percentile":8963.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9388.0,"maximum":35167.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26663.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30841.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29523.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27864.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18662.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22372.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9388.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35167.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23373.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34104.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30206.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25750.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12767.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29361.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10090.02,"10th_percentile":10090.02,"90th_percentile":10090.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6814.6,"maximum":25527.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19354.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21430.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20226.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13546.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16239.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6814.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25527.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24755.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21926.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18691.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9267.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21312.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5268.97,"10th_percentile":5268.97,"90th_percentile":5268.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18691.68,"10th_percentile":18691.68,"90th_percentile":18691.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9119.07,"10th_percentile":9119.07,"90th_percentile":9119.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5051.23,"maximum":18922.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14346.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16594.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15884.95},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14992.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10041.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12037.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18922.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18350.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16252.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13854.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6869.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15797.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13918.76,"10th_percentile":13918.76,"90th_percentile":13918.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9609.54,"10th_percentile":9609.54,"90th_percentile":9609.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","code_information":[{"code":"061","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15141.06,"maximum":56718.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43002.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49740.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47615.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44940.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30099.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36082.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15141.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56718.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37696.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55004.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48717.96},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41530.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20591.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47354.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25650.36,"10th_percentile":25650.36,"90th_percentile":25650.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10496.09,"10th_percentile":10496.09,"90th_percentile":10496.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","code_information":[{"code":"062","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9649.95,"maximum":36148.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27407.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31701.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30346.84},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28642.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19183.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22996.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9649.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36148.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24025.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35056.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31049.72},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26468.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13123.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30180.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13821.91,"10th_percentile":13821.91,"90th_percentile":13821.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","code_information":[{"code":"063","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7709.2,"maximum":28878.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21895.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25325.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24243.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18371.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7709.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28878.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19193.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28005.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24805.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21145.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24110.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10890.88,"10th_percentile":10890.88,"90th_percentile":10890.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22465.26,"10th_percentile":22465.26,"90th_percentile":22465.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21160.5,"10th_percentile":21160.5,"90th_percentile":21160.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11043.74,"maximum":41370.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31365.57},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36280.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34729.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32779.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21954.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26317.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11043.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41370.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27495.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40119.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35534.37},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30291.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15019.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34539.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20588.18,"10th_percentile":20588.18,"90th_percentile":20588.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15550.84,"10th_percentile":15550.84,"90th_percentile":15550.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15427.44,"10th_percentile":12405.87,"90th_percentile":18320.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17521.92,"10th_percentile":17521.92,"90th_percentile":17521.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15277.23,"10th_percentile":13989.22,"90th_percentile":15445.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14136.26,"10th_percentile":14136.26,"90th_percentile":14136.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","code_information":[{"code":"065","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5548.22,"maximum":20783.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15757.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18226.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17447.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16467.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11029.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13221.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5548.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20783.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13813.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20155.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17852.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15218.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7545.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17352.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7881.57,"10th_percentile":7799.81,"90th_percentile":7899.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7892.16,"10th_percentile":7892.16,"90th_percentile":7892.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":7882.67,"10th_percentile":7408.36,"90th_percentile":8860.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15166.05,"10th_percentile":15166.05,"90th_percentile":15166.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7753.18,"10th_percentile":5477.38,"90th_percentile":8046.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":952.97,"10th_percentile":952.97,"90th_percentile":6455.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","code_information":[{"code":"066","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3758.49,"maximum":14079.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10674.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12347.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11819.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11155.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7471.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8956.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3758.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14079.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12093.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5111.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5442.15,"10th_percentile":5442.15,"90th_percentile":5442.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5477.78,"10th_percentile":5477.78,"90th_percentile":5477.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8247.3,"10th_percentile":8247.3,"90th_percentile":8247.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5471.48,"10th_percentile":5471.48,"90th_percentile":5503.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction With Mcc","code_information":[{"code":"067","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8065.6,"maximum":30213.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22907.31},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26496.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25364.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23939.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16033.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19220.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8065.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30213.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20080.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29300.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25951.93},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22123.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10969.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25225.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7007.68,"10th_percentile":7007.68,"90th_percentile":7007.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9733.29,"10th_percentile":9733.29,"90th_percentile":9733.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction Without Mcc","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4746.99,"maximum":17782.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13482.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15594.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14928.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14089.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9436.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11312.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4746.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17782.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11818.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17244.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.95},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13020.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6455.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14846.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.53,"10th_percentile":6832.53,"90th_percentile":6832.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":280.07,"10th_percentile":280.07,"90th_percentile":280.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4386.74,"maximum":16432.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12458.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14411.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13795.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13020.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8720.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10453.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4386.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16432.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15936.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14114.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12032.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5965.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13719.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6259.66,"10th_percentile":6259.66,"90th_percentile":6259.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2859.45,"10th_percentile":2859.45,"90th_percentile":2859.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5330.79,"10th_percentile":755.07,"90th_percentile":6223.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13400.9,"10th_percentile":13400.9,"90th_percentile":13400.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1743.0,"10th_percentile":282.88,"90th_percentile":6264.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Mcc","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9142.52,"maximum":34248.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25965.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30034.66},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28751.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27136.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18174.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21787.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9142.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34248.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22762.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33212.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29417.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25076.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12433.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28593.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18451.5,"10th_percentile":18451.5,"90th_percentile":18451.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11867.29,"10th_percentile":11867.29,"90th_percentile":11867.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15488.27,"10th_percentile":15488.27,"90th_percentile":15488.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12393.56,"10th_percentile":280.08,"90th_percentile":13419.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15824.03,"10th_percentile":15824.03,"90th_percentile":15824.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Cc","code_information":[{"code":"071","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5634.44,"maximum":21106.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16002.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18510.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17719.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16723.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11200.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13427.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5634.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21106.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14028.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20468.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18129.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7662.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17621.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7294.93,"10th_percentile":7294.93,"90th_percentile":7294.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14673.75,"10th_percentile":14673.75,"90th_percentile":14673.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8181.13,"10th_percentile":8181.13,"90th_percentile":8181.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14711.19,"10th_percentile":14711.19,"90th_percentile":14711.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8212.93,"10th_percentile":8212.93,"90th_percentile":8212.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders Without Cc/Mcc","code_information":[{"code":"072","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4152.8,"maximum":15556.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11794.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13642.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13059.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12326.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8255.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9896.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4152.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15556.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10339.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15086.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11390.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5647.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12988.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":877.93,"10th_percentile":877.93,"90th_percentile":877.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8810.27,"maximum":33003.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25022.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28943.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27706.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26150.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17514.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20995.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8810.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33003.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21934.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28347.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24165.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11981.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders Without Mcc","code_information":[{"code":"074","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5660.8,"maximum":21205.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16077.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18596.66},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17801.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16802.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5660.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21205.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14093.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20564.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18214.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15526.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7698.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17704.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5107.22,"10th_percentile":5107.22,"90th_percentile":5107.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8100.68,"10th_percentile":8100.68,"90th_percentile":8100.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6091.22,"10th_percentile":188.96,"90th_percentile":7000.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis With Cc/Mcc","code_information":[{"code":"075","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10530.26,"maximum":39446.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29907.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34593.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33115.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31255.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20933.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25094.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10530.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39446.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26217.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38254.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33882.23},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14321.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32933.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":25944.51,"10th_percentile":25944.51,"90th_percentile":25944.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis Without Cc/Mcc","code_information":[{"code":"076","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4531.72,"maximum":16975.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12870.64},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14887.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14251.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13450.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9008.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10799.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4531.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16975.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11282.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16462.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.28},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12429.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6163.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14173.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma With Mcc","code_information":[{"code":"080","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9939.91,"maximum":37235.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28230.57},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32654.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31258.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29503.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19759.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23687.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9939.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37235.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24747.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31982.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27264.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13518.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31087.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15406.09,"10th_percentile":15406.09,"90th_percentile":15406.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14679.7,"10th_percentile":14679.7,"90th_percentile":14679.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma Without Mcc","code_information":[{"code":"081","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4918.34,"maximum":18424.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13968.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16157.52},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15467.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14598.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11720.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4918.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18424.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15825.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6688.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15382.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Mcc","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12551.74,"maximum":47019.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35648.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41234.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39472.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37255.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24951.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29911.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12551.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47019.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31250.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45597.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40386.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34427.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17070.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39255.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17283.48,"10th_percentile":17283.48,"90th_percentile":17283.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Cc","code_information":[{"code":"083","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7665.26,"maximum":28714.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21770.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25181.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24105.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22751.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15237.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18266.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28714.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27846.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24663.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21024.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10424.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23973.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9125.88,"10th_percentile":9125.88,"90th_percentile":9125.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":635.31,"10th_percentile":635.31,"90th_percentile":635.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","code_information":[{"code":"084","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5248.93,"maximum":19662.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14907.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17243.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16506.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15579.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10434.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12508.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5248.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19662.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13068.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16888.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14397.22},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7138.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16416.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12476.5,"maximum":46737.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35434.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40987.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39235.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37031.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24802.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29732.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12476.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46737.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31062.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45324.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40144.47},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34221.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16968.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39020.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17577.19,"10th_percentile":17577.19,"90th_percentile":17577.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32701.67,"10th_percentile":32701.67,"90th_percentile":32701.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17549.7,"10th_percentile":17549.7,"90th_percentile":17549.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Cc","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7153.99,"maximum":26798.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20318.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23502.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22497.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21234.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14221.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17048.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7153.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26798.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17811.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25988.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23018.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9729.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22374.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9409.77,"10th_percentile":9409.77,"90th_percentile":9409.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8515.59,"10th_percentile":8515.59,"90th_percentile":10180.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10185.38,"10th_percentile":10185.38,"90th_percentile":10185.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","code_information":[{"code":"087","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5023.22,"maximum":18817.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14266.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16502.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15796.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14909.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9985.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11970.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5023.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18817.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12506.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18248.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16162.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13778.13},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6831.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15710.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Mcc","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7423.63,"maximum":27809.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21084.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24387.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23345.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22034.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14757.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17691.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7423.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27809.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18482.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26968.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23886.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20362.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10096.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Cc","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6033.14,"maximum":22600.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17134.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19819.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18972.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17907.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11993.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14377.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6033.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22600.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15020.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21917.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19412.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16548.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8205.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18868.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion Without Cc/Mcc","code_information":[{"code":"090","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4520.74,"maximum":16934.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12839.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14851.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14216.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13418.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8986.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10773.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4520.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16934.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11255.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16422.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14545.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12399.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6148.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14138.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9644.46,"maximum":36128.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27391.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31683.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30329.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28626.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19172.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22983.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9644.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36128.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24011.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35036.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31032.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26453.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13116.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30163.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28431.77,"10th_percentile":28431.77,"90th_percentile":28431.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7129.59,"10th_percentile":7129.59,"90th_percentile":7129.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":28896.73,"10th_percentile":28896.73,"90th_percentile":28896.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13004.09,"10th_percentile":13004.09,"90th_percentile":13004.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14000.03,"10th_percentile":14000.03,"90th_percentile":14000.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15385.6,"10th_percentile":15385.6,"90th_percentile":15385.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":167.06,"10th_percentile":167.06,"90th_percentile":167.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14378.6,"10th_percentile":14378.6,"90th_percentile":14378.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5617.97,"maximum":21045.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15955.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18455.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17667.21},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16674.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11168.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5617.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21045.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13987.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20408.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18076.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15409.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7640.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17570.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8149.13,"10th_percentile":8149.13,"90th_percentile":8149.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1093.12,"10th_percentile":1093.12,"90th_percentile":1093.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7635.27,"10th_percentile":7635.27,"90th_percentile":7635.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63.69,"10th_percentile":63.69,"90th_percentile":63.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6239.41,"10th_percentile":157.58,"90th_percentile":8213.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4373.01,"maximum":16381.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12419.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14366.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13752.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12979.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8693.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10421.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4373.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16381.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10887.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15886.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14070.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5947.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13676.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","code_information":[{"code":"094","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19327.36,"maximum":72400.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54892.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63493.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60780.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57366.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38421.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46058.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19327.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72400.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48119.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70212.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62187.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53012.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26285.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60446.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Cc","code_information":[{"code":"095","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14164.1,"maximum":53058.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14164.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19263.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","code_information":[{"code":"096","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14164.1,"maximum":53058.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14164.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19263.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","code_information":[{"code":"097","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19834.78,"maximum":74301.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56333.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65160.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62375.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58872.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39430.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47267.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19834.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74301.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49382.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72055.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63820.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54404.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26975.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62033.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","code_information":[{"code":"098","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12602.81,"maximum":47210.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35793.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41402.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39632.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37406.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25053.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30033.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12602.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47210.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31377.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45783.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40550.88},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34568.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17139.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39415.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14871.19,"10th_percentile":14871.19,"90th_percentile":14871.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7481.84,"maximum":28027.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21249.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24579.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23528.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22207.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17829.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28027.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18627.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27179.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24073.61},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20521.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10175.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23399.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures With Mcc","code_information":[{"code":"100","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10636.25,"maximum":39843.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30208.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34941.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33448.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21144.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25346.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10636.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39843.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26481.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38639.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34223.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29174.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14465.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33265.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13677.78,"10th_percentile":13677.78,"90th_percentile":13677.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15408.75,"10th_percentile":14462.13,"90th_percentile":15413.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13601.11,"10th_percentile":13601.11,"90th_percentile":15408.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures Without Mcc","code_information":[{"code":"101","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4956.77,"maximum":18568.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14077.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16283.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15587.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14712.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9853.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11812.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4956.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18568.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12340.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18006.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15948.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6741.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15502.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1403.12,"10th_percentile":1403.12,"90th_percentile":1403.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14375.75,"10th_percentile":14375.75,"90th_percentile":14375.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5539.02,"10th_percentile":5539.02,"90th_percentile":5539.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7160.38,"10th_percentile":7160.38,"90th_percentile":7160.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13595.86,"10th_percentile":13595.86,"90th_percentile":13595.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5334.46,"10th_percentile":5334.46,"90th_percentile":5334.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7178.38,"10th_percentile":7178.38,"90th_percentile":7233.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6155.6,"maximum":23059.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17482.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20222.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19357.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18270.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12236.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14669.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6155.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23059.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22361.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19806.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16884.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8371.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19251.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18545.29,"10th_percentile":18545.29,"90th_percentile":18545.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9619.66,"10th_percentile":9619.66,"90th_percentile":9619.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4592.68,"maximum":17204.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13043.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15087.69},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14442.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13631.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9129.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4592.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17204.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11434.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16684.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14777.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12597.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14363.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6241.62,"10th_percentile":6241.62,"90th_percentile":6241.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12679.88,"10th_percentile":12679.88,"90th_percentile":12679.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures With Cc/Mcc","code_information":[{"code":"113","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12911.44,"maximum":48366.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36670.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42416.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40603.5},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38322.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25666.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30768.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12911.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48366.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32145.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46904.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41543.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35414.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17559.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40380.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures Without Cc/Mcc","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7430.22,"maximum":27833.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21102.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24409.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23366.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22053.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14770.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27833.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18499.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26992.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23907.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10105.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23238.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extraocular Procedures Except Orbit","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8429.15,"maximum":31575.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23939.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27691.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26507.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25018.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16756.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20087.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8429.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31575.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20986.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30621.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27121.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23120.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11463.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26362.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10214.8,"10th_percentile":10214.8,"90th_percentile":10214.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures With Cc/Mcc","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9929.48,"maximum":37195.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28200.94},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32619.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31225.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29472.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19739.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23662.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9929.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37195.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24721.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36071.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.13},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27235.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13504.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31054.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures Without Cc/Mcc","code_information":[{"code":"117","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5957.9,"maximum":22318.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16921.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19572.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18736.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17683.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11843.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14198.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5957.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22318.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14833.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21643.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19170.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16341.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8102.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18633.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections With Cc/Mcc","code_information":[{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6388.45,"maximum":23931.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18143.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20987.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20090.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18961.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12699.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15224.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6388.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23931.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15905.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23207.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17522.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8688.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19980.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections Without Cc/Mcc","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4315.35,"maximum":16165.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12256.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14176.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13570.77},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12808.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8578.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10283.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4315.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16165.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10743.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15676.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13885.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11836.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5868.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13496.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4385.64,"maximum":16428.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12455.76},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14407.54},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13791.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13017.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8718.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10451.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16428.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14111.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12029.31},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5964.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13716.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20075.44,"10th_percentile":20075.44,"90th_percentile":20075.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","code_information":[{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7266.02,"maximum":27218.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20636.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23870.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22849.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21566.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14444.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17315.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7266.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27218.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18090.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26395.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23379.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19929.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9881.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22724.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4216.5,"maximum":15795.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11975.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13851.88},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13259.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12515.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8382.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10048.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4216.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15795.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10497.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15317.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13567.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11565.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5734.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13187.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6429.27,"10th_percentile":6429.27,"90th_percentile":6429.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7659.95,"10th_percentile":7659.95,"90th_percentile":7659.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures With Cc/Mcc","code_information":[{"code":"135","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11916.91,"maximum":44640.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33845.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39148.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37475.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35371.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23689.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28398.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11916.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44640.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43291.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38343.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32686.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16206.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37270.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures Without Cc/Mcc","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5575.69,"maximum":20886.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15835.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18317.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17534.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16549.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11084.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13287.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5575.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20886.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13881.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17940.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15293.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures With Cc/Mcc","code_information":[{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8200.15,"maximum":30717.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23289.44},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26938.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25787.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24339.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19541.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8200.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30717.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20415.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26384.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22492.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11152.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25646.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures Without Cc/Mcc","code_information":[{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4866.71,"maximum":18230.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13822.06},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15987.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15304.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14445.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9674.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11597.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4866.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18230.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12116.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17679.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6618.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15220.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures","code_information":[{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6786.04,"maximum":25420.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19273.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22293.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21340.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20141.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16171.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6786.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25420.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16895.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24652.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21834.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18613.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9229.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21223.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Mcc","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23423.59,"maximum":87745.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66525.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76950.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73661.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69524.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46564.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55819.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23423.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87745.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58317.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85092.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75367.85},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64248.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31856.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73258.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Cc","code_information":[{"code":"141","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11977.86,"maximum":44869.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34018.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39349.23},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37667.6},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35551.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23811.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28544.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11977.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44869.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29821.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43512.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38540.04},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32853.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16289.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37461.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures Without Cc/Mcc","code_information":[{"code":"142","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8766.89,"maximum":32840.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24899.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28800.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27569.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26021.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17427.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20892.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8766.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32840.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21826.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31848.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28208.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24046.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11922.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27418.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","code_information":[{"code":"143","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20575.06,"maximum":77074.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58435.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67592.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64703.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61069.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40901.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49031.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20575.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77074.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51225.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74744.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66202.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56435.04},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27982.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64349.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","code_information":[{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9516.5,"maximum":35648.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27028.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31263.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29927.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28246.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18918.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22678.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9516.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35648.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23693.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34571.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30620.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26102.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12942.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29763.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12638.7,"10th_percentile":12638.7,"90th_percentile":12638.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","code_information":[{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6602.62,"maximum":24733.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18752.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21690.69},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20763.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19597.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13125.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15734.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6602.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24733.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23985.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21244.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18110.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8979.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20649.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11628.04,"maximum":43558.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33025.09},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38200.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36567.5},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34513.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27710.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11628.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43558.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28950.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42242.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37414.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31894.4},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15814.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36367.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Cc","code_information":[{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6982.65,"maximum":26157.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19831.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21958.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20725.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13880.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16640.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6982.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26157.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17384.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25366.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19152.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9496.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21838.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","code_information":[{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4377.4,"maximum":16397.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12432.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14380.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13765.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12992.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8701.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4377.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16397.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10898.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15902.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14084.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12006.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5953.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13690.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4127.54,"maximum":15461.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11722.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13559.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12980.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12251.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8205.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9836.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15461.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10276.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14994.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13280.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11321.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12908.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1731.22,"10th_percentile":1731.22,"90th_percentile":5821.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis With Mcc","code_information":[{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7312.15,"maximum":27391.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20767.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24021.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22995.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21703.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14535.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17425.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7312.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27391.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18205.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23527.61},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20056.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9944.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis Without Mcc","code_information":[{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4030.88,"maximum":15099.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11448.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13242.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12676.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11964.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8013.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9605.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4030.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15099.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10035.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11056.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5482.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6492.24,"maximum":24320.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18438.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21328.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20416.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19269.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12906.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15471.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6492.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24320.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23584.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20889.47},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17807.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8829.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20304.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":719.96,"10th_percentile":719.96,"90th_percentile":719.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4053.94,"maximum":15186.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11513.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13317.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12748.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12032.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8058.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9660.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4053.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15186.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10093.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14727.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13043.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11119.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5513.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12678.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17851.29,"10th_percentile":17851.29,"90th_percentile":17851.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5622.01,"10th_percentile":5622.01,"90th_percentile":5622.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5641.11,"10th_percentile":5641.11,"90th_percentile":5648.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8586.21,"maximum":32164.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24385.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28207.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27001.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25485.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17068.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20461.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8586.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32164.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21377.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31191.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27627.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23551.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11677.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26853.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5033.11,"maximum":18854.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14294.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16534.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15827.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14938.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10005.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5033.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18854.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12530.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18284.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13805.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6845.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15741.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8434.14,"10th_percentile":8434.14,"90th_percentile":8434.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","code_information":[{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3795.28,"maximum":14217.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10779.09},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.14},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11935.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11264.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7544.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9044.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3795.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14217.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9449.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13787.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12211.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10410.04},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5161.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11869.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1476.89,"10th_percentile":1476.89,"90th_percentile":1476.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Mcc","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9428.08,"maximum":35317.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26776.93},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30972.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29649.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27983.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18742.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9428.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35317.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23473.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34250.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30335.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25860.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12822.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29486.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4996.31,"maximum":18716.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14190.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16413.7},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15712.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14829.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9932.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11906.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4996.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18716.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12439.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18150.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16076.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6794.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15626.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6706.55,"10th_percentile":6706.55,"90th_percentile":6706.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":2418.6,"10th_percentile":2418.6,"90th_percentile":2418.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.58,"10th_percentile":282.58,"90th_percentile":282.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases Without Cc/Mcc","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3890.84,"maximum":14575.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11050.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12782.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12235.8},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11548.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7734.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3890.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14575.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9687.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14134.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.14},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5291.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12168.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Mcc","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24612.53,"maximum":92198.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69902.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80856.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77400.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73053.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48927.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58653.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24612.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":92198.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61277.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89411.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79193.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67509.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33473.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76976.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":71889.69,"10th_percentile":71889.69,"90th_percentile":71889.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":69374.06,"10th_percentile":69374.06,"90th_percentile":69374.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35713.79,"10th_percentile":35713.79,"90th_percentile":35713.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":59508.05,"10th_percentile":59508.05,"90th_percentile":59508.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":68741.61,"10th_percentile":68741.61,"90th_percentile":68741.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":43558.54,"10th_percentile":43558.54,"90th_percentile":43558.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":79159.47,"10th_percentile":79159.47,"90th_percentile":79159.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Major Chest Procedures With Cc","code_information":[{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13860.95,"maximum":51923.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39366.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45535.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43589.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41141.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33031.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13860.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51923.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34509.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50353.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44599.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38019.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18850.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43350.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18915.45,"10th_percentile":18915.45,"90th_percentile":18915.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":39257.65,"10th_percentile":39257.65,"90th_percentile":39257.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20053.19,"10th_percentile":20053.19,"90th_percentile":20053.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19520.85,"10th_percentile":19515.65,"90th_percentile":23481.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":50210.16,"10th_percentile":50210.16,"90th_percentile":50210.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19530.16,"10th_percentile":19530.16,"90th_percentile":19530.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures Without Cc/Mcc","code_information":[{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10512.14,"maximum":39378.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29855.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34534.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33058.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31201.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20897.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25051.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10512.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39378.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26172.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38188.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33823.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28833.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14296.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32877.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":61515.94,"10th_percentile":61515.94,"90th_percentile":61515.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13550.87,"10th_percentile":13550.87,"90th_percentile":13550.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":86507.8,"10th_percentile":86507.8,"90th_percentile":86507.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5110.38,"10th_percentile":5110.38,"90th_percentile":5110.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13382.06,"10th_percentile":13382.06,"90th_percentile":13382.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14436.3,"10th_percentile":14436.3,"90th_percentile":14436.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20526.19,"maximum":76891.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58296.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67431.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64550.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60924.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40804.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48915.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20526.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76891.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51104.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74567.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66045.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56300.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27915.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64196.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34800.76,"10th_percentile":34800.76,"90th_percentile":34800.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28031.29,"10th_percentile":28031.29,"90th_percentile":28031.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Cc","code_information":[{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9903.66,"maximum":37099.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28127.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32535.14},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31144.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29395.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19687.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23601.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9903.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37099.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24657.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35977.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31866.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27164.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13468.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30974.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12534.28,"10th_percentile":12534.28,"90th_percentile":12534.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7503.81,"maximum":28109.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21311.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24651.22},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23597.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22272.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14916.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17882.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7503.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28109.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18682.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24144.29},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20582.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10205.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23468.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","code_information":[{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16345.38,"maximum":61230.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46422.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53697.23},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51402.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48515.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32493.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38952.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16345.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":61230.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40695.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59379.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52592.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44833.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22229.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51120.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":49244.54,"10th_percentile":49244.54,"90th_percentile":49244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23619.93,"10th_percentile":23619.93,"90th_percentile":23619.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23645.13,"10th_percentile":23645.13,"90th_percentile":23645.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26107.89,"10th_percentile":26107.89,"90th_percentile":26107.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7543.35,"maximum":28257.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21424.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24781.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23722.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22389.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14995.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17976.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7543.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28257.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18780.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27403.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24271.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20690.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10258.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23592.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8509.68,"10th_percentile":8509.68,"90th_percentile":8509.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11514.91,"10th_percentile":11514.91,"90th_percentile":11514.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9183.65,"10th_percentile":9183.65,"90th_percentile":9183.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10946.18,"10th_percentile":10946.18,"90th_percentile":12784.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":18051.95,"10th_percentile":18051.95,"90th_percentile":18051.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21015.32,"10th_percentile":21015.32,"90th_percentile":21015.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10953.18,"10th_percentile":10953.18,"90th_percentile":12779.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4420.78,"maximum":16560.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12555.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14523.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13902.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13121.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8788.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10535.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4420.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16560.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16059.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14224.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12125.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6012.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13826.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8891.9,"10th_percentile":8891.9,"90th_percentile":8891.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6324.64,"10th_percentile":6324.64,"90th_percentile":6325.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6363.22,"10th_percentile":6363.22,"90th_percentile":6363.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12268.81,"10th_percentile":12268.81,"90th_percentile":12268.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6357.73,"10th_percentile":6357.73,"90th_percentile":6357.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8581.82,"maximum":32147.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24373.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28192.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26987.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25472.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17060.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20451.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8581.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32147.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31175.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27612.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23538.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11671.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10839.37,"10th_percentile":10839.37,"90th_percentile":10843.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20776.0,"10th_percentile":20776.0,"90th_percentile":20776.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8058.96,"10th_percentile":8058.96,"90th_percentile":8058.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8147.24,"10th_percentile":8147.24,"90th_percentile":8147.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12535.96,"10th_percentile":12535.96,"90th_percentile":12535.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10876.98,"10th_percentile":10876.98,"90th_percentile":10876.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"22","median_amount":12529.96,"10th_percentile":11233.93,"90th_percentile":14202.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21490.58,"10th_percentile":21490.58,"90th_percentile":21490.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24349.34,"10th_percentile":24349.34,"90th_percentile":24349.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":11966.38,"10th_percentile":10559.46,"90th_percentile":12559.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5359.86,"maximum":20078.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15222.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16855.52},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15908.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10654.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12772.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5359.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20078.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13344.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19471.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17245.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14701.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7289.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16763.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7437.48,"10th_percentile":7195.41,"90th_percentile":7659.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7655.99,"10th_percentile":7655.99,"90th_percentile":7655.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7716.61,"10th_percentile":7636.49,"90th_percentile":7727.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13059.79,"10th_percentile":13059.79,"90th_percentile":13059.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14944.0,"10th_percentile":14944.0,"90th_percentile":14944.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7691.52,"10th_percentile":7606.92,"90th_percentile":13463.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4146.2,"maximum":15531.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11775.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13620.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13038.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12306.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8242.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9880.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4146.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15531.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10322.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15062.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13340.85},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11372.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5638.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12967.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6046.55,"10th_percentile":6046.55,"90th_percentile":6046.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7900.12,"10th_percentile":7900.12,"90th_percentile":7900.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":688.4,"10th_percentile":688.4,"90th_percentile":688.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9698.27,"maximum":36329.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27544.3},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31860.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30498.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28785.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19279.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23111.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9698.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36329.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24145.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35231.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31205.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26601.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13189.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30331.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13453.34,"10th_percentile":13453.34,"90th_percentile":13453.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12044.35,"10th_percentile":12044.35,"90th_percentile":12044.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Cc","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5881.57,"maximum":22032.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16704.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19321.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18496.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17457.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11692.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14016.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5881.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22032.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18924.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16132.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7998.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18394.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8599.05,"10th_percentile":8599.05,"90th_percentile":8599.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms Without Cc/Mcc","code_information":[{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4139.62,"maximum":15507.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11757.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13599.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12286.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8229.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9864.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4139.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15507.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10306.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15038.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13319.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11354.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12946.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8401.7,"maximum":31472.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23861.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27600.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26421.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24937.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16701.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20021.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8401.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31472.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20917.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30521.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23044.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11426.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26276.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10961.38,"10th_percentile":10961.38,"90th_percentile":10961.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Cc","code_information":[{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5843.68,"maximum":21890.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16596.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19197.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18377.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17344.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11616.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13925.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5843.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21890.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14549.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21228.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16028.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7947.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18276.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":10000.0,"10th_percentile":10000.0,"90th_percentile":10000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":400.18,"10th_percentile":400.18,"90th_percentile":400.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8285.02,"10th_percentile":8278.51,"90th_percentile":8288.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.88,"10th_percentile":282.88,"90th_percentile":282.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8469.85,"10th_percentile":8469.85,"90th_percentile":8469.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":24485.78,"10th_percentile":24485.78,"90th_percentile":24485.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4319.19,"maximum":16179.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12267.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14189.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13582.86},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12819.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8586.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10292.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4319.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16179.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10753.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15690.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13897.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11847.05},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5874.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13508.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Mcc","code_information":[{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8558.75,"maximum":32061.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24307.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28116.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26915.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25403.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17014.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20396.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8558.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32061.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21308.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31092.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27538.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23475.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11639.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26767.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12236.76,"10th_percentile":12236.76,"90th_percentile":12236.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12269.76,"10th_percentile":12269.76,"90th_percentile":12269.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":264.31,"10th_percentile":264.31,"90th_percentile":264.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Cc","code_information":[{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5431.8,"maximum":20347.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15426.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17844.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17081.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16122.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12944.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5431.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20347.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14898.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7387.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16988.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7621.03,"10th_percentile":7621.03,"90th_percentile":7621.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":142.88,"10th_percentile":142.88,"90th_percentile":142.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3938.62,"maximum":14754.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11186.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12939.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12386.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11690.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7829.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9386.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3938.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14754.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14308.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10803.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5356.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12318.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6784.4,"maximum":25414.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19268.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22287.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21335.36},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20137.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13486.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16167.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6784.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25414.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16891.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24646.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21829.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18608.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9226.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21218.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8308.65,"10th_percentile":8308.65,"90th_percentile":8308.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9815.27,"10th_percentile":7848.81,"90th_percentile":11493.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4670.69,"10th_percentile":4670.69,"90th_percentile":4670.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":19299.73,"10th_percentile":18881.36,"90th_percentile":20439.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11237.15,"10th_percentile":11237.15,"90th_percentile":11237.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":13508.7,"10th_percentile":13508.7,"90th_percentile":13508.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"18","median_amount":9044.41,"10th_percentile":6653.54,"90th_percentile":9616.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4394.5,"10th_percentile":4394.5,"90th_percentile":4394.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8586.52,"10th_percentile":8586.52,"90th_percentile":8586.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9589.71,"10th_percentile":8966.01,"90th_percentile":11202.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18454.58,"10th_percentile":13288.58,"90th_percentile":18638.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"25","median_amount":8152.62,"10th_percentile":5348.25,"90th_percentile":9623.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8166.73,"10th_percentile":8166.73,"90th_percentile":8226.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6083.12,"maximum":22787.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17276.8},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19984.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19129.98},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18055.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12092.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14496.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6083.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22787.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22098.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19573.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16685.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8273.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19025.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7830.1,"10th_percentile":7830.1,"90th_percentile":7830.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":12259.8,"10th_percentile":12259.8,"90th_percentile":12259.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7066.08,"10th_percentile":6556.1,"90th_percentile":7722.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8662.97,"10th_percentile":8631.48,"90th_percentile":9751.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13040.62,"10th_percentile":13040.62,"90th_percentile":13040.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11715.99,"10th_percentile":11715.99,"90th_percentile":11715.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8644.08,"10th_percentile":6582.61,"90th_percentile":8722.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7293.55,"10th_percentile":7293.55,"90th_percentile":7293.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4629.47,"maximum":17342.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13148.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15208.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14558.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13740.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9203.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11032.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4629.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17342.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11526.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16817.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14895.81},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12698.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14478.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13947.44,"10th_percentile":13947.44,"90th_percentile":13947.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6629.26,"10th_percentile":6629.26,"90th_percentile":6629.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4962.07,"10th_percentile":4962.07,"90th_percentile":4962.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6406.01,"10th_percentile":807.06,"90th_percentile":6748.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12940.62,"10th_percentile":12940.62,"90th_percentile":12940.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5083.92,"10th_percentile":4725.78,"90th_percentile":6706.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","code_information":[{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3525.64,"maximum":13207.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10013.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11582.32},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11087.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10464.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7008.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8401.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3525.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13207.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8777.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12807.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11344.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9670.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4794.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11026.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7218.24,"maximum":27039.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20500.7},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23713.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22699.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21424.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14349.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17201.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7218.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27039.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17971.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26222.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23225.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19798.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9816.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22575.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6766.96,"10th_percentile":6766.96,"90th_percentile":6766.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10227.51,"10th_percentile":8616.31,"90th_percentile":12228.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18552.17,"10th_percentile":18552.17,"90th_percentile":18552.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":11735.1,"10th_percentile":11735.1,"90th_percentile":11735.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8490.31,"10th_percentile":8490.31,"90th_percentile":8490.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9063.73,"10th_percentile":4251.72,"90th_percentile":10224.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"26","median_amount":10210.81,"10th_percentile":8588.31,"90th_percentile":11713.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11543.56,"10th_percentile":11069.05,"90th_percentile":30888.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6766.96,"10th_percentile":6364.49,"90th_percentile":6766.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"24","median_amount":9887.38,"10th_percentile":6421.02,"90th_percentile":10268.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10409.41,"10th_percentile":8896.58,"90th_percentile":10895.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4425.73,"maximum":16578.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12569.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14539.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13917.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13136.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8798.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10546.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4425.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16578.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11018.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16077.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14240.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12139.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6018.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13841.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4458.69,"10th_percentile":4458.69,"90th_percentile":4458.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5855.12,"10th_percentile":4580.02,"90th_percentile":6410.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":21697.95,"10th_percentile":21697.95,"90th_percentile":21697.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":10231.69,"10th_percentile":10231.69,"90th_percentile":10231.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6361.71,"10th_percentile":6361.71,"90th_percentile":6361.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4499.98,"10th_percentile":4499.98,"90th_percentile":4499.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4681.62,"10th_percentile":4681.62,"90th_percentile":4681.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":6404.02,"10th_percentile":5584.52,"90th_percentile":6714.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12351.66,"10th_percentile":12351.66,"90th_percentile":12351.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":6421.03,"10th_percentile":6005.93,"90th_percentile":6436.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3451.51,"maximum":12929.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9802.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11338.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10854.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10244.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6861.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8225.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3451.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12929.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12538.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11105.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9467.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4694.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10794.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":9712.25,"10th_percentile":9712.25,"90th_percentile":9712.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5023.46,"10th_percentile":5023.46,"90th_percentile":5023.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5030.27,"10th_percentile":5030.27,"90th_percentile":5030.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Mcc","code_information":[{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10363.87,"maximum":38823.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29434.66},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34046.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32591.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30761.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24697.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10363.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38823.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25802.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37649.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33346.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28426.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14094.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32413.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17082.05,"10th_percentile":17082.05,"90th_percentile":17082.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12803.47,"10th_percentile":12803.47,"90th_percentile":12803.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Cc","code_information":[{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5212.14,"maximum":19524.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14803.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17122.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16390.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15470.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10361.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12420.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5212.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19524.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18934.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16770.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14296.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7088.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":71.25,"10th_percentile":71.25,"90th_percentile":71.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease Without Cc/Mcc","code_information":[{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3933.13,"maximum":14733.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11170.57},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12920.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12368.77},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11674.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7818.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9372.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3933.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14733.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9792.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12655.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10788.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5349.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12300.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9687.84,"maximum":36290.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27514.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31826.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30466.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28754.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19258.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23086.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9687.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36290.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35193.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31171.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26572.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13175.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30299.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14030.58,"10th_percentile":14030.58,"90th_percentile":14030.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":24586.9,"10th_percentile":24586.9,"90th_percentile":24586.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Cc","code_information":[{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6036.98,"maximum":22614.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17145.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19832.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18984.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17918.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12001.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14386.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6036.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22614.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15030.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21931.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19424.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16558.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8210.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18880.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":554.0,"10th_percentile":554.0,"90th_percentile":554.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8597.75,"10th_percentile":8597.75,"90th_percentile":8597.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":19866.11,"10th_percentile":19866.11,"90th_percentile":19866.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":30200.41,"10th_percentile":30200.41,"90th_percentile":30200.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3927.09,"maximum":14710.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11153.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12901.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12349.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11656.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7806.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9358.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3927.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14710.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10771.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5340.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12282.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10902.26,"10th_percentile":10902.26,"90th_percentile":10902.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10098.27,"10th_percentile":10098.27,"90th_percentile":10098.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5333.5,"maximum":19979.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15147.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17521.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15830.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10602.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12710.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5333.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19979.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13278.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19375.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17161.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14629.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7253.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16680.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7983.84,"10th_percentile":7983.84,"90th_percentile":7983.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1239.22,"10th_percentile":1239.22,"90th_percentile":1239.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6326.58,"10th_percentile":6326.58,"90th_percentile":6326.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7493.19,"10th_percentile":7392.96,"90th_percentile":9046.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7075.44,"10th_percentile":7075.44,"90th_percentile":7508.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma Without Cc/Mcc","code_information":[{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3679.41,"maximum":13783.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10449.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12087.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11570.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10921.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7314.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8768.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3679.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13783.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9160.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13366.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11838.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10092.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5004.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11507.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Signs And Symptoms","code_information":[{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4433.97,"maximum":16609.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12593.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14566.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13943.8},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13160.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8814.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10566.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4433.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16609.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11039.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16107.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12161.87},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6030.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13867.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":586.89,"10th_percentile":586.89,"90th_percentile":586.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10055.24,"maximum":37667.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28558.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33033.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31621.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29845.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19989.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23962.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10055.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37667.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25034.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36528.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32353.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27580.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13675.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31448.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13753.62,"10th_percentile":13753.62,"90th_percentile":13753.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14620.62,"10th_percentile":14620.62,"90th_percentile":14620.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5168.2,"maximum":19360.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14678.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16252.8},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15339.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10273.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12316.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5168.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19360.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12867.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18774.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16629.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14175.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7028.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6474.51,"10th_percentile":6474.51,"90th_percentile":6474.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":571.5,"10th_percentile":571.5,"90th_percentile":571.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","code_information":[{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35337.2,"maximum":132373.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":100362.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116088.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111127.27},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104885.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70247.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84210.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35337.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":132373.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87979.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128372.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113701.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96925.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48058.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110518.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15094.93,"maximum":56545.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42871.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49589.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44803.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30007.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35972.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15094.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56545.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37581.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54836.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48569.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41403.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20529.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47209.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20822.48,"10th_percentile":20822.48,"90th_percentile":20822.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":39186.44,"10th_percentile":39186.44,"90th_percentile":39186.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20801.98,"10th_percentile":20794.08,"90th_percentile":22468.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8279.7,"10th_percentile":8279.7,"90th_percentile":8279.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14361.9,"10th_percentile":14361.9,"90th_percentile":14361.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19013.71,"10th_percentile":18825.48,"90th_percentile":20785.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex Aortic Arch Procedures","code_information":[{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62159.02,"maximum":232848.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":176539.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204202.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195475.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184496.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123567.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148129.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62159.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":232848.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154757.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":225810.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200003.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170495.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84536.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194404.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Aortic And Mitral Valve Procedures","code_information":[{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59716.88,"maximum":223700.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":169603.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":196179.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187795.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":177247.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142309.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59716.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":223700.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148677.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216938.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192145.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163796.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81214.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":186766.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Abdominal Aorta With Iliac Branch Procedures","code_information":[{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31340.36,"maximum":117401.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":89010.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102958.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98558.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93022.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62302.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74686.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31340.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":117401.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78028.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113852.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100840.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85963.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42622.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98018.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Heart Assist System Implant","code_information":[{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54680.48,"maximum":204834.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":155299.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179634.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171957.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162299.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108700.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130307.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54680.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":204834.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136138.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198642.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175940.19},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149982.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74365.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171014.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":135201.36,"10th_percentile":135201.36,"90th_percentile":135201.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":159589.47,"10th_percentile":159589.47,"90th_percentile":159589.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":78656.5,"10th_percentile":78656.5,"90th_percentile":78656.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","code_information":[{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53723.83,"maximum":201250.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":152582.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176491.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168948.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159459.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106798.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128027.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53723.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":201250.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133756.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195166.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172862.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147358.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73064.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168023.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":150528.21,"10th_percentile":150528.21,"90th_percentile":150528.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":75195.97,"10th_percentile":75195.97,"90th_percentile":75195.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":74762.26,"10th_percentile":74752.76,"90th_percentile":89518.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":103892.89,"10th_percentile":103892.89,"90th_percentile":103892.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","code_information":[{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36109.33,"maximum":135266.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36109.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49108.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50020.59,"10th_percentile":50020.59,"90th_percentile":50020.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","code_information":[{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36109.33,"maximum":135266.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36109.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49108.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","code_information":[{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42166.63,"maximum":157956.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":119758.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138524.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132604.24},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125156.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83824.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100485.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42166.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":157956.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104982.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153182.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135675.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115658.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57346.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131877.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59925.32,"10th_percentile":59925.32,"90th_percentile":59925.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":120681.79,"10th_percentile":120681.79,"90th_percentile":120681.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59967.32,"10th_percentile":59967.32,"90th_percentile":59967.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59958.32,"10th_percentile":59958.32,"90th_percentile":59958.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":159164.48,"10th_percentile":159164.48,"90th_percentile":159164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":116549.96,"10th_percentile":116549.96,"90th_percentile":116549.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59925.32,"10th_percentile":59925.32,"90th_percentile":59925.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","code_information":[{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29285.93,"maximum":109705.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":83175.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96209.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92097.46},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86924.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58218.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69790.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29285.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":109705.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72913.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106389.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94230.58},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80327.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39828.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91592.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50625.6,"10th_percentile":50625.6,"90th_percentile":50625.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":73402.67,"10th_percentile":73402.67,"90th_percentile":73402.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":82612.63,"10th_percentile":82612.63,"90th_percentile":82612.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":115363.96,"10th_percentile":115363.96,"90th_percentile":115363.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":40801.61,"10th_percentile":40801.61,"90th_percentile":41057.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41054.85,"10th_percentile":41043.85,"90th_percentile":50481.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79784.19,"10th_percentile":79784.19,"90th_percentile":79784.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41058.35,"10th_percentile":41058.35,"90th_percentile":41058.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27679.07,"maximum":103686.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78612.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90930.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87044.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82155.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55023.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65961.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27679.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":103686.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68912.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100551.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89060.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75920.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37643.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86567.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures With Mcc","code_information":[{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27169.45,"maximum":101777.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77164.6},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89256.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85441.6},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80642.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54010.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64746.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27169.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":101777.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67643.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98700.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87420.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74522.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36950.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84973.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38600.51,"10th_percentile":38600.51,"90th_percentile":38600.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7249.09,"10th_percentile":7249.09,"90th_percentile":7249.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38594.61,"10th_percentile":38594.61,"90th_percentile":38594.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38511.62,"10th_percentile":38511.62,"90th_percentile":38511.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures Without Mcc","code_information":[{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17295.99,"maximum":64791.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49122.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56820.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54391.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51336.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34383.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41217.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17295.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64791.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43061.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62832.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55651.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47440.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23522.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54093.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24063.55,"10th_percentile":24063.55,"90th_percentile":24063.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":107461.25,"10th_percentile":107461.25,"90th_percentile":107461.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23926.61,"10th_percentile":23926.61,"90th_percentile":23926.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24071.65,"10th_percentile":24071.65,"90th_percentile":24071.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24064.65,"10th_percentile":24064.65,"90th_percentile":24064.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca With Mcc","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46294.16,"maximum":173418.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":131481.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152083.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145584.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137407.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92029.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110322.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46294.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":173418.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115258.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168176.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148956.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126979.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62960.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144786.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca Without Mcc","code_information":[{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33293.75,"maximum":124718.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94558.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109375.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104701.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98820.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66185.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79341.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33293.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":124718.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82891.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120948.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107126.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91320.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45279.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104127.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","code_information":[{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41984.85,"maximum":157275.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":119242.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137927.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132032.6},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124616.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83462.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100052.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41984.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":157275.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104529.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152521.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135090.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115159.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57099.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131308.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":252519.86,"10th_percentile":252519.86,"90th_percentile":252519.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":60569.4,"10th_percentile":60569.4,"90th_percentile":60569.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":117738.43,"10th_percentile":117738.43,"90th_percentile":117738.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":83169.73,"10th_percentile":83169.73,"90th_percentile":83169.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","code_information":[{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29999.3,"maximum":112377.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85201.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98552.57},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94340.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89042.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59636.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71490.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29999.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112377.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74689.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108980.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96525.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82284.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40799.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93823.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":34232.08,"10th_percentile":34232.08,"90th_percentile":34232.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41231.34,"10th_percentile":41231.34,"90th_percentile":41231.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":112377.9,"10th_percentile":112377.9,"90th_percentile":112377.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79045.46,"10th_percentile":79045.46,"90th_percentile":79045.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41248.84,"10th_percentile":41248.84,"90th_percentile":49398.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization With Mcc","code_information":[{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32228.37,"maximum":120728.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":91532.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105875.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101350.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95658.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64067.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76802.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32228.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":120728.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80239.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117078.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103698.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88398.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43830.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100795.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":128109.29,"10th_percentile":128109.29,"90th_percentile":128109.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":53111.68,"10th_percentile":53111.68,"90th_percentile":53111.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23003.48,"maximum":86171.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65332.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75570.14},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72340.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68277.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45729.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54818.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23003.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86171.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57271.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83566.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74016.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63095.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31284.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71944.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31654.3,"10th_percentile":31654.3,"90th_percentile":31654.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":64136.42,"10th_percentile":64136.42,"90th_percentile":64136.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31878.86,"10th_percentile":31668.56,"90th_percentile":37454.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":84587.37,"10th_percentile":84587.37,"90th_percentile":84587.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32009.3,"10th_percentile":32009.3,"90th_percentile":32009.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27028.31,"maximum":101248.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76763.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88792.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84997.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80223.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53730.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64410.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27028.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":101248.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67292.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98187.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86966.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74135.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36758.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84531.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":45788.47,"10th_percentile":45788.47,"90th_percentile":45788.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":39044.76,"10th_percentile":39044.76,"90th_percentile":39044.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15653.98,"maximum":58640.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44459.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51425.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49228.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46463.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31118.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37304.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15653.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58640.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38973.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56867.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50368.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42937.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21289.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48958.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21905.62,"10th_percentile":21905.62,"90th_percentile":21905.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7602.66,"maximum":28479.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21592.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24975.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23908.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22565.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15113.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18117.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7602.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28479.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18928.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27618.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20853.22},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10339.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23777.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Mcc","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17533.78,"maximum":65681.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49798.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57601.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55139.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52042.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34855.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41784.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17533.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65681.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43653.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63696.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56416.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48093.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23845.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54837.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26288.05,"10th_percentile":26288.05,"90th_percentile":26288.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26125.03,"10th_percentile":16660.51,"90th_percentile":26302.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":26283.95,"10th_percentile":25530.85,"90th_percentile":26304.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28251.23,"10th_percentile":26137.25,"90th_percentile":36322.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Cc","code_information":[{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11702.18,"maximum":43836.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33235.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38443.57},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36800.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34733.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23263.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27887.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11702.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43836.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29134.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42511.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37653.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15914.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36598.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16291.07,"10th_percentile":15723.47,"90th_percentile":17769.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17458.47,"10th_percentile":17046.64,"90th_percentile":19852.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":35611.37,"10th_percentile":35611.37,"90th_percentile":35611.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33933.93,"10th_percentile":33933.93,"90th_percentile":33933.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17761.47,"10th_percentile":16857.51,"90th_percentile":18249.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9926.18,"maximum":37183.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28191.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32609.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31215.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29462.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23654.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9926.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37183.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24713.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36059.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31938.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27226.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13499.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31044.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13977.02,"10th_percentile":13977.02,"90th_percentile":13977.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13984.52,"10th_percentile":13984.52,"90th_percentile":13984.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13984.93,"10th_percentile":13984.93,"90th_percentile":13984.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Generator Procedures","code_information":[{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25055.16,"maximum":93857.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71159.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82310.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78792.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74367.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49807.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59708.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25055.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93857.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62379.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91019.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80617.61},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68723.43},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34075.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78360.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","code_information":[{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11985.56,"maximum":44898.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34040.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39374.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37691.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35574.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23826.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28562.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11985.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44898.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29840.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43540.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38564.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32875.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16300.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37485.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8207.29,"maximum":30744.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23309.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26962.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25810.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24360.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16315.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19558.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30744.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29815.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26407.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22511.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11161.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25668.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12107.51,"10th_percentile":12107.51,"90th_percentile":12107.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Mcc","code_information":[{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19156.57,"maximum":71760.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54407.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62932.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60242.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56859.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38081.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45651.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19156.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71760.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47694.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69591.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61638.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52544.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26052.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59912.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26567.74,"10th_percentile":26567.74,"90th_percentile":26567.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26586.14,"10th_percentile":26586.14,"90th_percentile":26586.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26585.82,"10th_percentile":26585.82,"90th_percentile":26585.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26567.74,"10th_percentile":26567.74,"90th_percentile":26567.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Cc","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14254.16,"maximum":53396.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40483.57},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46827.22},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44826.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42308.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28336.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33968.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14254.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53396.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35488.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51782.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45864.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39097.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19385.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44580.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19807.45,"10th_percentile":19807.45,"90th_percentile":19807.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18478.85,"10th_percentile":18478.85,"90th_percentile":18478.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24147.87,"10th_percentile":19794.45,"90th_percentile":24180.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":38888.86,"10th_percentile":38888.86,"90th_percentile":38888.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19548.96,"10th_percentile":18189.75,"90th_percentile":22599.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures Without Cc/Mcc","code_information":[{"code":"254","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9784.49,"maximum":36652.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27789.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32143.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30769.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19450.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23317.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9784.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36652.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24360.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35544.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31482.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26837.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13306.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30601.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11949.38,"10th_percentile":11949.38,"90th_percentile":11949.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15348.76,"10th_percentile":15348.76,"90th_percentile":15348.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14813.2,"maximum":55490.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42071.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48663.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46584.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43967.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29447.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35300.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14813.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55490.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36880.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53813.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47663.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40630.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20145.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46328.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25094.95,"10th_percentile":25094.95,"90th_percentile":25094.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9324.29,"maximum":34928.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26482.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30631.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29322.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27675.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22220.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9324.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34928.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23214.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33873.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30001.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12681.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29162.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13117.36,"10th_percentile":13117.36,"90th_percentile":13117.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","code_information":[{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5997.99,"maximum":22468.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17035.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19704.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18862.29},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17802.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11923.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14293.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5997.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22468.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14933.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21789.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19299.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16451.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8157.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18758.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement With Mcc","code_information":[{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17255.35,"maximum":64638.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49007.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56686.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54264.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51216.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34302.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41120.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17255.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64638.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42960.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62684.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55520.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47329.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23467.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53966.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement Without Mcc","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11104.69,"maximum":41598.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31538.69},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36480.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34921.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32960.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22075.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26463.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11104.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41598.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27647.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40340.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35730.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30458.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15102.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34730.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","code_information":[{"code":"260","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17863.28,"maximum":66916.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50733.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58683.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56175.86},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53020.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35510.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42569.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17863.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66916.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44474.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64893.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57476.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48996.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24294.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55867.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","code_information":[{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10381.99,"maximum":38891.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14119.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","code_information":[{"code":"262","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8950.86,"maximum":33530.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25421.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29405.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28148.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26567.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17793.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21330.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8950.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33530.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22284.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32516.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28800.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24551.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12173.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27994.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein Ligation And Stripping","code_information":[{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16790.21,"maximum":62896.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47686.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55158.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52801.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49835.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33377.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40012.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16790.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62896.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41802.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60995.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54024.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46053.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22834.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52511.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17518.01,"10th_percentile":17518.01,"90th_percentile":17518.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28444.17,"10th_percentile":28444.17,"90th_percentile":28444.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures","code_information":[{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18345.44,"maximum":68722.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52103.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60267.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57692.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54451.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36469.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43718.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18345.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":68722.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45674.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66644.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59028.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50319.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24949.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57375.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27082.42,"10th_percentile":27082.42,"90th_percentile":27082.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31078.89,"10th_percentile":31078.89,"90th_percentile":103369.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Lead Procedures","code_information":[{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19869.93,"maximum":74433.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56433.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65275.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62486.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58976.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39499.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47351.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19869.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74433.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49470.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72183.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63933.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54500.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27023.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62143.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","code_information":[{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33655.1,"maximum":126072.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95584.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110562.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105837.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99892.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66903.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80202.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33655.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":126072.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83791.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122261.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108288.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92312.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45770.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105257.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46402.99,"10th_percentile":46014.37,"90th_percentile":46851.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46401.0,"10th_percentile":46401.0,"90th_percentile":46403.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46429.1,"10th_percentile":46397.51,"90th_percentile":46538.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","code_information":[{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26144.71,"maximum":97938.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74254.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85889.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82219.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77601.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51973.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62304.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26144.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":97938.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65092.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94977.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84123.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71711.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35556.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81768.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36442.82,"10th_percentile":36442.82,"90th_percentile":36442.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36436.92,"10th_percentile":36218.48,"90th_percentile":36442.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36442.42,"10th_percentile":36167.42,"90th_percentile":44297.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":37960.44,"10th_percentile":36441.17,"90th_percentile":70913.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","code_information":[{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37771.1,"maximum":141491.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":107274.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124084.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118781.33},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112109.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75086.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90011.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37771.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":141491.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94038.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137214.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121532.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103601.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51368.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118130.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":51322.52,"10th_percentile":51322.52,"90th_percentile":51322.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","code_information":[{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23192.38,"maximum":86879.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65869.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76190.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72934.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68838.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46104.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55269.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23192.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86879.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57742.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84252.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74623.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63614.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31541.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72534.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21554.33,"10th_percentile":21554.33,"90th_percentile":21554.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32230.05,"10th_percentile":32230.05,"90th_percentile":32237.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":32023.94,"10th_percentile":32023.94,"90th_percentile":32023.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32276.52,"10th_percentile":32276.52,"90th_percentile":38902.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28975.66,"maximum":108543.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82294.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95189.73},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91121.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86003.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57601.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69050.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28975.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":108543.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72140.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105262.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93232.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79476.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39406.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90622.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":48539.62,"10th_percentile":48539.62,"90th_percentile":48539.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":87296.38,"10th_percentile":87296.38,"90th_percentile":87296.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4662.06,"10th_percentile":4662.06,"90th_percentile":4662.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38144.59,"10th_percentile":38144.59,"90th_percentile":53705.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79476.91,"10th_percentile":76653.56,"90th_percentile":88666.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41920.24,"10th_percentile":41920.24,"90th_percentile":41920.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Cc","code_information":[{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19530.0,"maximum":73159.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55467.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64159.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61417.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57967.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38824.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46541.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19530.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73159.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48623.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70948.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62839.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53568.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26560.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61080.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26682.06,"10th_percentile":26682.06,"90th_percentile":26682.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26523.57,"10th_percentile":26523.57,"90th_percentile":26523.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26676.16,"10th_percentile":26676.16,"90th_percentile":26676.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":70582.35,"10th_percentile":70582.35,"90th_percentile":70582.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":51369.78,"10th_percentile":51369.78,"90th_percentile":51369.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures Without Cc/Mcc","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14020.22,"maximum":52519.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39819.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46058.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44090.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41613.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27871.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33411.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14020.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52519.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34906.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50932.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45111.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38455.84},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19067.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43848.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures With Mcc","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22655.85,"maximum":84869.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64345.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74428.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71247.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67245.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45038.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53990.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22655.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84869.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56406.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82303.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72897.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62142.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30811.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70856.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34920.68,"10th_percentile":34920.68,"90th_percentile":34920.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30098.74,"10th_percentile":30098.74,"90th_percentile":30098.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":37523.62,"10th_percentile":30291.26,"90th_percentile":41205.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30300.26,"10th_percentile":30300.26,"90th_percentile":30300.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures Without Mcc","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18076.9,"maximum":67716.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51340.64},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59385.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53654.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35935.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43078.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18076.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67716.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45006.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65669.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58164.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49582.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24584.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56536.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24171.5,"10th_percentile":23882.4,"90th_percentile":24182.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":48682.2,"10th_percentile":48682.2,"90th_percentile":48682.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24178.49,"10th_percentile":24178.49,"90th_percentile":24178.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":64970.63,"10th_percentile":64970.63,"90th_percentile":64970.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":24176.99,"10th_percentile":24028.77,"90th_percentile":25731.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"67","median_amount":24177.0,"10th_percentile":24028.78,"90th_percentile":30354.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":42672.22,"10th_percentile":42672.22,"90th_percentile":42672.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":62259.96,"10th_percentile":62259.96,"90th_percentile":62259.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":47011.62,"10th_percentile":46546.59,"90th_percentile":48958.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"28","median_amount":24178.81,"10th_percentile":24043.05,"90th_percentile":30491.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23077.14,"10th_percentile":23077.14,"90th_percentile":23077.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","code_information":[{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39157.75,"maximum":146685.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111212.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128639.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123142.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116225.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77842.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93315.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39157.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":146685.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97491.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142251.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125994.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107405.22},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53254.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122467.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":62914.91,"10th_percentile":62914.91,"90th_percentile":62914.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":106450.22,"10th_percentile":106450.22,"90th_percentile":106450.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","code_information":[{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32986.21,"maximum":123566.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93684.94},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108365.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103733.98},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97907.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65574.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78608.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32986.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":123566.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82125.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119831.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106136.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90477.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44861.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103165.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Mcc","code_information":[{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25363.24,"maximum":95011.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72034.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83322.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79761.5},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75281.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50420.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60442.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25363.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95011.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63146.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92139.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81608.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69568.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34494.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79324.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":40826.39,"10th_percentile":40826.39,"90th_percentile":40826.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35889.0,"10th_percentile":35889.0,"90th_percentile":35889.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36408.88,"10th_percentile":36408.88,"90th_percentile":36408.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30567.69,"maximum":114507.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86816.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100419.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96128.27},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90729.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60766.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72844.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30567.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":114507.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76104.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111045.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98354.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83843.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41572.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95601.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38749.52,"10th_percentile":38749.52,"90th_percentile":38749.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","code_information":[{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19805.13,"maximum":74190.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56249.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65063.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62282.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58784.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39371.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47196.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19805.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74190.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49308.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71947.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63725.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54323.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26934.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61941.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8809.18,"maximum":32999.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25019.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28939.57},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27702.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26146.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20992.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8809.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32999.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21932.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32001.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28344.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24162.56},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11980.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27550.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12712.3,"10th_percentile":12712.3,"90th_percentile":12712.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12712.3,"10th_percentile":6763.27,"90th_percentile":12755.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12616.3,"10th_percentile":11795.3,"90th_percentile":14429.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24479.84,"10th_percentile":24479.84,"90th_percentile":24479.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8450.52,"10th_percentile":8450.52,"90th_percentile":8450.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12229.68,"10th_percentile":12229.68,"90th_percentile":12229.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12966.54,"10th_percentile":12966.54,"90th_percentile":12966.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5047.39,"maximum":18907.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14335.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16581.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15872.86},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14981.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10033.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12028.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5047.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18907.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18336.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16240.5},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13844.4},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6864.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15785.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7402.35,"10th_percentile":7402.35,"90th_percentile":7402.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14377.31,"10th_percentile":14377.31,"90th_percentile":14377.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7155.64,"10th_percentile":7155.64,"90th_percentile":7155.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7139.14,"10th_percentile":6850.04,"90th_percentile":8550.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13747.73,"10th_percentile":13747.73,"90th_percentile":13747.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7141.65,"10th_percentile":6789.75,"90th_percentile":7174.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3971.02,"maximum":14875.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11278.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13045.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11786.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7894.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9463.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3971.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14875.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9886.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14425.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12777.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10892.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5400.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12419.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11309.38,"10th_percentile":11309.38,"90th_percentile":11309.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":15869.02,"10th_percentile":15869.02,"90th_percentile":15869.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6075.78,"10th_percentile":5735.98,"90th_percentile":6732.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10442.73,"10th_percentile":10442.73,"90th_percentile":10442.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5912.23,"10th_percentile":5912.23,"90th_percentile":5912.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5739.12,"10th_percentile":5739.12,"90th_percentile":5739.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10877.89,"maximum":40748.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30894.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35735.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34208.42},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32287.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21624.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25922.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10877.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40748.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27082.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39516.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35000.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29836.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14793.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34020.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":91368.32,"10th_percentile":91368.32,"90th_percentile":91368.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9615.39,"10th_percentile":9615.39,"90th_percentile":9615.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15445.07,"10th_percentile":15445.07,"90th_percentile":15445.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Cc","code_information":[{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3801.33,"maximum":14239.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10796.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11954.29},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11282.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7556.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9058.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3801.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14239.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9464.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13809.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12231.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10426.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5169.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11888.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired Without Cc/Mcc","code_information":[{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3288.96,"maximum":12320.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9341.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10804.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10343.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9762.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6538.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7837.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3288.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12320.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8188.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11948.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10582.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9021.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4472.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10286.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12151.95,"maximum":45521.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34513.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38215.06},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36068.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24157.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28958.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12151.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45521.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30254.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44145.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39100.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33331.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16526.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38005.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20616.03,"10th_percentile":20616.03,"90th_percentile":20616.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17158.04,"10th_percentile":17036.42,"90th_percentile":19743.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":17152.55,"10th_percentile":16025.65,"90th_percentile":17523.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":19193.53,"10th_percentile":19193.53,"90th_percentile":19193.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32984.78,"10th_percentile":32984.78,"90th_percentile":32984.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13598.27,"10th_percentile":13598.27,"90th_percentile":13598.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17162.56,"10th_percentile":16406.56,"90th_percentile":19898.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","code_information":[{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5876.62,"maximum":22013.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16690.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19305.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18480.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17442.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11682.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5876.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22013.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14631.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21348.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18908.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16118.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7992.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18379.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8473.03,"10th_percentile":8445.41,"90th_percentile":8501.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":26851.49,"10th_percentile":26851.49,"90th_percentile":26851.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8445.0,"10th_percentile":8445.0,"90th_percentile":8450.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7578.3,"10th_percentile":7578.3,"90th_percentile":7578.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":8445.01,"10th_percentile":8310.01,"90th_percentile":8458.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10065.5,"10th_percentile":10065.5,"90th_percentile":10065.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9237.86,"10th_percentile":9237.86,"90th_percentile":9237.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16251.79,"10th_percentile":16251.79,"90th_percentile":16793.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9237.86,"10th_percentile":9237.86,"90th_percentile":9237.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":8442.11,"10th_percentile":7835.23,"90th_percentile":9269.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8576.85,"10th_percentile":8576.85,"90th_percentile":8576.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Mcc","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14861.54,"maximum":55671.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42208.6},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48822.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46736.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44111.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29543.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35416.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14861.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55671.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37000.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53988.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47818.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40763.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20211.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46479.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Cc","code_information":[{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9373.72,"maximum":35114.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26622.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30794.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29478.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27822.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18634.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22338.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9373.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35114.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23337.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34052.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30160.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25711.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12748.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29316.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis Without Cc/Mcc","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5105.6,"maximum":19125.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14500.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16055.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15154.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10149.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12166.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5105.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19125.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12711.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18547.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16427.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6943.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15967.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7050.2,"maximum":26410.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20023.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23161.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22171.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20925.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14015.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16801.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7050.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26410.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17552.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25611.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22684.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19337.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9588.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22049.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5077.75,"10th_percentile":5077.75,"90th_percentile":5077.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9204.82,"10th_percentile":8918.01,"90th_percentile":10164.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17743.44,"10th_percentile":17743.44,"90th_percentile":17743.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":19893.71,"10th_percentile":19893.71,"90th_percentile":19893.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7907.85,"10th_percentile":7907.85,"90th_percentile":7907.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":26671.72,"10th_percentile":26671.72,"90th_percentile":26671.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5077.75,"10th_percentile":5077.75,"90th_percentile":5077.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9701.38,"10th_percentile":9701.38,"90th_percentile":9701.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":9800.8,"10th_percentile":9234.94,"90th_percentile":10210.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8462.92,"10th_percentile":8462.92,"90th_percentile":8462.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"66","median_amount":10111.7,"10th_percentile":8763.79,"90th_percentile":11257.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28029.84,"10th_percentile":28029.84,"90th_percentile":28029.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":18111.63,"10th_percentile":18111.63,"90th_percentile":18111.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":19436.53,"10th_percentile":9487.95,"90th_percentile":25011.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7152.72,"10th_percentile":5078.27,"90th_percentile":7531.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10076.94,"10th_percentile":10076.94,"90th_percentile":10076.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"53","median_amount":9983.69,"10th_percentile":8071.9,"90th_percentile":10145.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8729.7,"10th_percentile":8729.7,"90th_percentile":8729.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4662.42,"maximum":17465.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13241.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15316.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14662.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13838.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9268.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4662.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17465.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11608.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16937.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12788.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6340.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6351.31,"10th_percentile":6351.31,"90th_percentile":6351.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6159.65,"10th_percentile":6159.65,"90th_percentile":6628.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6701.18,"10th_percentile":6701.18,"90th_percentile":6701.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":420.08,"10th_percentile":420.08,"90th_percentile":420.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock Without Cc/Mcc","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3108.28,"maximum":11643.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8827.9},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10211.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9774.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9225.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6179.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7407.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3108.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11643.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7738.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11291.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10001.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8525.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4227.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9721.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Mcc","code_information":[{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8577.43,"maximum":32131.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24360.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28178.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26974.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25458.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17051.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20440.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8577.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32131.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21355.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31159.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27598.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23526.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11665.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26826.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11140.67,"10th_percentile":11140.67,"90th_percentile":11140.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Cc","code_information":[{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3481.71,"maximum":13042.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9888.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11437.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10949.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10334.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6921.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8297.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3481.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13042.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8668.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12648.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11202.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4735.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10889.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained Without Cc/Mcc","code_information":[{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2499.26,"maximum":9362.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":7098.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8210.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7859.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7418.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4968.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5955.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2499.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9362.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6222.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9079.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8041.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6855.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3398.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7816.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8966.24,"maximum":33587.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25465.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29455.54},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28196.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26613.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17824.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21367.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8966.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33587.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22323.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32572.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28849.81},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12194.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28042.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12527.98,"10th_percentile":12527.98,"90th_percentile":12527.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14547.58,"10th_percentile":14547.58,"90th_percentile":14547.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13296.22,"10th_percentile":13296.22,"90th_percentile":13296.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5862.35,"maximum":21960.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16649.8},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19258.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18435.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17400.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11653.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13970.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21960.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14595.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21296.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18862.73},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16079.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7972.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18334.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8022.08,"10th_percentile":8022.08,"90th_percentile":8022.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":1629.78,"10th_percentile":1629.78,"90th_percentile":1629.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8341.59,"10th_percentile":8341.59,"90th_percentile":8341.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders Without Cc/Mcc","code_information":[{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3952.35,"maximum":14805.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11225.16},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12984.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12429.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11731.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9418.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3952.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14805.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9840.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14358.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12717.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10840.84},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5375.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12361.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.29,"10th_percentile":6832.29,"90th_percentile":6832.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":843.46,"10th_percentile":843.46,"90th_percentile":843.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis With Mcc","code_information":[{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6571.32,"maximum":24616.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21587.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20665.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19504.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13063.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6571.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24616.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16360.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23872.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21143.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18024.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8937.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20552.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6266.56,"10th_percentile":6266.56,"90th_percentile":6266.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis Without Mcc","code_information":[{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3696.99,"maximum":13848.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10499.9},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12145.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11626.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10973.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7349.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8810.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13848.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9204.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13430.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11895.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10140.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5027.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11562.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5345.8,"10th_percentile":5345.8,"90th_percentile":5345.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6263.04,"10th_percentile":6263.04,"90th_percentile":6263.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6535.08,"maximum":24480.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18560.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21468.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20551.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19397.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12991.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15573.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6535.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24480.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16270.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23740.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21027.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17924.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8887.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20438.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7138.58,"10th_percentile":7138.58,"90th_percentile":7138.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4146.76,"maximum":15533.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11777.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13622.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13040.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12308.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8243.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9881.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4146.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15533.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10324.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15064.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13342.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11374.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5639.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4881.06,"10th_percentile":4881.06,"90th_percentile":4881.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7041.48,"10th_percentile":7041.48,"90th_percentile":7041.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11307.79,"10th_percentile":11307.79,"90th_percentile":11307.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5872.46,"10th_percentile":5402.12,"90th_percentile":6004.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders With Mcc","code_information":[{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8653.76,"maximum":32417.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24577.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28429.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27214.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25685.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17203.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20622.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8653.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32417.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21545.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31437.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27844.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23736.28},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11769.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27064.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10342.53,"10th_percentile":10342.53,"90th_percentile":10342.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders Without Mcc","code_information":[{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5014.99,"maximum":18786.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14243.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16475.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15770.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14885.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9969.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5014.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18786.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12485.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18218.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13755.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6820.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6611.96,"maximum":24768.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6611.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8992.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":15004.25,"10th_percentile":15004.25,"90th_percentile":15004.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18808.42,"10th_percentile":18808.42,"90th_percentile":18808.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":13164.82,"10th_percentile":13164.82,"90th_percentile":13164.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9356.94,"10th_percentile":9356.94,"90th_percentile":9356.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18164.47,"10th_percentile":18164.47,"90th_percentile":18164.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.38,"10th_percentile":81.38,"90th_percentile":81.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9107.28,"10th_percentile":7379.44,"90th_percentile":9375.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4040.21,"maximum":15134.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11474.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13272.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12705.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11991.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8031.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9628.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4040.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15134.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10058.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12999.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11081.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5494.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5831.24,"10th_percentile":5653.04,"90th_percentile":5840.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":17434.35,"10th_percentile":17434.35,"90th_percentile":17434.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8070.95,"10th_percentile":8070.95,"90th_percentile":8070.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4592.1,"10th_percentile":4592.1,"90th_percentile":4592.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":5531.01,"10th_percentile":4905.14,"90th_percentile":5843.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":15208.78,"10th_percentile":15208.78,"90th_percentile":15208.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11260.0,"10th_percentile":11260.0,"90th_percentile":11260.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11136.08,"10th_percentile":7704.54,"90th_percentile":11136.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5798.18,"10th_percentile":459.52,"90th_percentile":6844.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4367.12,"10th_percentile":4367.12,"90th_percentile":4367.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3108.83,"maximum":11645.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8829.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10213.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9776.55},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9227.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6180.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7408.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3108.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11645.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7740.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11293.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10002.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8527.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4228.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9722.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4631.45,"10th_percentile":4631.45,"90th_percentile":4631.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8740.09,"10th_percentile":8740.09,"90th_percentile":8740.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":26265.75,"10th_percentile":26265.75,"90th_percentile":26265.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4982.44,"10th_percentile":4982.44,"90th_percentile":4982.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4649.25,"10th_percentile":4554.64,"90th_percentile":5391.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3397.94,"10th_percentile":3397.94,"90th_percentile":3397.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8344.38,"10th_percentile":8344.38,"90th_percentile":8344.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4842.53,"10th_percentile":4842.53,"90th_percentile":4842.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Angina Pectoris","code_information":[{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3854.6,"maximum":14439.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10947.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12662.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12121.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11440.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7662.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9185.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3854.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14439.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9596.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14002.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12402.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10572.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5242.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12055.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4786.53,"maximum":17930.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13594.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15724.54},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15052.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14207.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9515.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11406.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4786.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17930.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11917.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17388.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15401.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6509.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14970.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5481.58,"10th_percentile":5481.58,"90th_percentile":6793.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14420.62,"10th_percentile":14420.62,"90th_percentile":14420.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6751.98,"10th_percentile":6751.98,"90th_percentile":6751.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":6753.53,"10th_percentile":125.0,"90th_percentile":6876.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1132.39,"10th_percentile":157.58,"90th_percentile":6838.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6890.5,"10th_percentile":6890.5,"90th_percentile":6890.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3954.0,"maximum":14811.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11229.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12989.52},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12434.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11736.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7860.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9422.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3954.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14811.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9844.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14364.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12722.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10845.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5377.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12366.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5661.15,"10th_percentile":5661.15,"90th_percentile":5661.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6343.75,"10th_percentile":6343.75,"90th_percentile":6343.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6428.95,"10th_percentile":6428.95,"90th_percentile":6428.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2222.84,"10th_percentile":2222.84,"90th_percentile":2222.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11451.21,"maximum":42896.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32522.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37619.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36011.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33988.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22764.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27289.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11451.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42896.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28510.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41599.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36845.48},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31409.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15573.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35814.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14949.92,"10th_percentile":14949.92,"90th_percentile":14949.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17519.91,"10th_percentile":17519.91,"90th_percentile":19432.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17067.95,"10th_percentile":17067.95,"90th_percentile":17067.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16187.34,"10th_percentile":16187.34,"90th_percentile":16187.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5290.12,"maximum":19816.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15024.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17378.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16636.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15701.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10516.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5290.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19816.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13170.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19217.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17021.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14510.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7194.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16545.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":15008.99,"10th_percentile":15008.99,"90th_percentile":15008.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7407.11,"10th_percentile":7407.11,"90th_percentile":7407.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7496.91,"10th_percentile":7496.91,"90th_percentile":16678.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5942.5,"10th_percentile":5942.5,"90th_percentile":5942.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5492.81,"10th_percentile":5492.81,"90th_percentile":5492.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses Without Cc/Mcc","code_information":[{"code":"316","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3745.86,"maximum":14032.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10638.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12305.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11779.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11118.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7446.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8926.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3745.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14032.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9326.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13607.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12052.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10274.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5094.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11715.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11285.34,"10th_percentile":11285.34,"90th_percentile":11285.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1305.11,"10th_percentile":1305.11,"90th_percentile":1305.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","code_information":[{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36720.0,"maximum":137553.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104289.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120631.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115475.86},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108989.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72996.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87506.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36720.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":137553.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91421.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133395.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118150.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100718.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49939.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114842.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54224.01,"10th_percentile":54224.01,"90th_percentile":54224.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":74425.5,"10th_percentile":74425.5,"90th_percentile":74425.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":110628.14,"10th_percentile":110628.14,"90th_percentile":110628.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50758.1,"10th_percentile":50758.1,"90th_percentile":50758.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63614.49,"10th_percentile":54229.51,"90th_percentile":68533.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":68527.29,"10th_percentile":68527.29,"90th_percentile":68535.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy Without Intraluminal Device","code_information":[{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13301.9,"maximum":49829.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37779.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43698.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41831.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39481.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26443.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31699.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13301.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49829.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33117.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48322.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42800.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36485.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18090.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41602.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures With Mcc","code_information":[{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24508.74,"maximum":91810.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69607.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80515.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77074.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72745.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48721.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58405.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24508.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":91810.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61019.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89034.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78859.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67224.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33331.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76651.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34054.33,"10th_percentile":34054.33,"90th_percentile":34054.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures Without Mcc","code_information":[{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13209.1,"maximum":49481.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37515.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43394.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41539.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39206.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26258.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31478.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13209.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49481.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32886.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47985.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42501.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36231.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17964.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41311.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","code_information":[{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14941.71,"maximum":55971.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42436.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49085.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46988.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44349.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29702.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35607.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14941.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55971.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37200.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54279.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48076.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40983.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20320.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46730.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21912.67,"10th_percentile":20313.27,"90th_percentile":25312.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":43646.69,"10th_percentile":43646.69,"90th_percentile":43646.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":44357.32,"10th_percentile":44357.32,"90th_percentile":44357.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22997.71,"10th_percentile":22997.71,"90th_percentile":22997.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22053.36,"10th_percentile":21778.37,"90th_percentile":27358.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19339.84,"10th_percentile":19339.84,"90th_percentile":19339.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22051.37,"10th_percentile":20969.87,"90th_percentile":22192.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":56856.23,"10th_percentile":56856.23,"90th_percentile":56856.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":52126.2,"10th_percentile":52126.2,"90th_percentile":52126.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":42457.18,"10th_percentile":42457.18,"90th_percentile":42457.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":22047.88,"10th_percentile":21332.48,"90th_percentile":22084.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29901.75,"10th_percentile":29901.75,"90th_percentile":29901.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","code_information":[{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9681.8,"maximum":36268.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27497.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30447.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28736.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19246.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23072.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36268.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24104.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35171.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31152.21},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26556.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13167.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30280.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14045.4,"10th_percentile":14045.4,"90th_percentile":14045.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":33546.47,"10th_percentile":33546.47,"90th_percentile":33546.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28218.09,"10th_percentile":27290.15,"90th_percentile":28218.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":43025.75,"10th_percentile":43025.75,"90th_percentile":43025.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":20878.16,"10th_percentile":20878.16,"90th_percentile":20878.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13931.46,"10th_percentile":13742.38,"90th_percentile":16410.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":38878.86,"10th_percentile":38878.86,"90th_percentile":38878.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":14013.85,"10th_percentile":13931.46,"90th_percentile":14029.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":36132.58,"10th_percentile":36132.58,"90th_percentile":36132.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24736.49,"10th_percentile":24736.49,"90th_percentile":24736.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":50214.18,"10th_percentile":50214.18,"90th_percentile":50214.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"15","median_amount":26982.0,"10th_percentile":26556.07,"90th_percentile":27251.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":14018.89,"10th_percentile":13263.37,"90th_percentile":16401.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12714.32,"10th_percentile":12714.32,"90th_percentile":12714.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23764.62,"maximum":89022.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67494.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78070.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74734.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70536.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47242.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56632.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23764.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":89022.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59166.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86331.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76465.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65183.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32319.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74324.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32988.18,"10th_percentile":32988.18,"90th_percentile":32988.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33020.63,"10th_percentile":33020.63,"90th_percentile":33020.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33041.59,"10th_percentile":33041.59,"90th_percentile":33041.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","code_information":[{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17304.22,"maximum":64821.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49146.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54417.77},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51361.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34399.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41237.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17304.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64821.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43082.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62862.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55678.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23533.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54119.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23102.91,"10th_percentile":23102.91,"90th_percentile":23102.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":34169.63,"10th_percentile":34169.63,"90th_percentile":34169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24323.99,"10th_percentile":24323.99,"90th_percentile":24745.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29316.15,"10th_percentile":24758.99,"90th_percentile":29328.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":23045.85,"10th_percentile":23045.85,"90th_percentile":23045.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24753.7,"10th_percentile":22785.39,"90th_percentile":29314.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy Without Intraluminal Device","code_information":[{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17630.43,"maximum":66043.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50072.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57918.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55443.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52329.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35047.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42014.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17630.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66043.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43894.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64047.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56727.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48358.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55139.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Mcc","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27389.12,"maximum":102600.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77788.48},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89977.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86132.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81294.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54447.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65270.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27389.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102600.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68190.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99498.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88127.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75125.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37249.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85660.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":39040.17,"10th_percentile":39040.17,"90th_percentile":39040.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Cc","code_information":[{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13422.72,"maximum":50281.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38122.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44095.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42211.33},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39840.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26683.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31987.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13422.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50281.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33418.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48761.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43189.01},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36816.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18254.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41979.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","code_information":[{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8799.29,"maximum":32962.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24991.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28907.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27671.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26117.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17492.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20969.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8799.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32962.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21907.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31965.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28312.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24135.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11967.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27520.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25242.43,"maximum":94558.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71691.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82925.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79381.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74922.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50179.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60154.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25242.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94558.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62846.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91700.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81220.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69237.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34329.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78946.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":90.0,"10th_percentile":90.0,"90th_percentile":90.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":82196.54,"10th_percentile":82196.54,"90th_percentile":82196.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":71619.86,"10th_percentile":71619.86,"90th_percentile":71619.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35586.32,"10th_percentile":35586.32,"90th_percentile":35586.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35563.32,"10th_percentile":34739.28,"90th_percentile":35607.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":69167.79,"10th_percentile":69167.79,"90th_percentile":69167.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35598.32,"10th_percentile":35598.32,"90th_percentile":42054.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13164.62,"maximum":49314.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37389.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43247.89},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41399.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39074.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26170.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31372.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13164.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49314.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32775.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47824.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42358.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17903.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41172.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17149.97,"10th_percentile":17149.97,"90th_percentile":17149.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":24955.95,"10th_percentile":24955.95,"90th_percentile":24955.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17889.37,"10th_percentile":17889.37,"90th_percentile":17889.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18339.37,"10th_percentile":17336.61,"90th_percentile":18339.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35604.41,"10th_percentile":35604.41,"90th_percentile":35604.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18306.38,"10th_percentile":18306.38,"90th_percentile":18306.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9241.92,"maximum":34620.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26248.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30361.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29063.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27431.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18372.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22024.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9241.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34620.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23009.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33573.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29736.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12569.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28904.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14995.31,"10th_percentile":14995.31,"90th_percentile":14995.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11753.66,"10th_percentile":11753.66,"90th_percentile":11753.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9848.89,"10th_percentile":9848.89,"90th_percentile":9848.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12794.56,"10th_percentile":12794.56,"90th_percentile":12794.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Mcc","code_information":[{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19883.66,"maximum":74484.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56472.06},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65321.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62529.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59017.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39527.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47384.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19883.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74484.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49504.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72232.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63977.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54538.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27041.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62186.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Cc","code_information":[{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12862.57,"maximum":48183.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36531.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42255.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40449.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25569.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30652.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12862.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48183.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32023.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46726.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41386.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35280.56},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17493.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40228.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8994.8,"maximum":33694.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25546.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29549.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28286.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26697.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17880.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21435.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8994.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33694.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22394.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32676.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28941.69},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24671.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12232.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28131.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19610.18,"maximum":73460.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55695.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64422.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61669.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58205.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38983.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46732.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19610.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73460.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48823.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71239.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63097.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53788.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26669.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61331.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26420.01,"10th_percentile":26420.01,"90th_percentile":26420.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26745.49,"10th_percentile":26745.49,"90th_percentile":26745.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Cc","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11580.27,"maximum":43379.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32889.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38043.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36417.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34371.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23020.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27596.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11580.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43379.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28831.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42068.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37260.73},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31763.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15749.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36217.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15019.02,"10th_percentile":15019.02,"90th_percentile":15019.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16504.23,"10th_percentile":16504.23,"90th_percentile":16504.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16359.33,"10th_percentile":16359.33,"90th_percentile":16359.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis Without Cc/Mcc","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8429.7,"maximum":31577.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23941.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27692.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26509.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25020.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16757.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8429.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31577.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20987.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30623.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27123.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23121.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11464.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26364.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11889.03,"10th_percentile":11889.03,"90th_percentile":12228.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Mcc","code_information":[{"code":"344","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14183.86,"maximum":53133.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40283.93},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46596.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44604.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42099.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28196.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33801.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14183.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53133.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35313.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51526.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45638.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38904.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19290.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44360.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Cc","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8263.3,"maximum":30954.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23468.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27146.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25986.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24526.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16426.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19692.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8263.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30954.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30018.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26588.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22665.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25843.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":16528.07,"10th_percentile":16528.07,"90th_percentile":16528.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11529.68,"10th_percentile":11529.68,"90th_percentile":11529.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6514.21,"maximum":24402.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18501.16},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21400.23},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19335.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15523.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6514.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24402.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16218.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23664.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20960.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8859.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20373.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Mcc","code_information":[{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12606.66,"maximum":47224.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35804.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41414.92},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39645.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37418.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30042.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12606.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47224.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31386.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45797.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40563.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34578.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17145.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39427.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7187.49,"maximum":26924.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20413.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23612.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22602.98},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21333.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17128.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7187.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26924.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17894.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26110.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.5},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19714.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9774.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22479.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9761.9,"10th_percentile":9761.9,"90th_percentile":9761.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures Without Cc/Mcc","code_information":[{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4781.04,"maximum":17909.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13578.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15706.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15035.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14190.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9504.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11393.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4781.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17909.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11903.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17368.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.5},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13113.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6502.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14952.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6822.4,"10th_percentile":6822.4,"90th_percentile":6822.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13684.67,"maximum":51263.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38866.16},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44956.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43035.11},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40617.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27204.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32611.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13684.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51263.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34070.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49713.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44031.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37535.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18611.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42799.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11679.55,"10th_percentile":11679.55,"90th_percentile":11679.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18748.13,"10th_percentile":18748.13,"90th_percentile":18748.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8372.04,"maximum":31361.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23777.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27503.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26328.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24849.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16642.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19951.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8372.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31361.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20843.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30413.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22963.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11385.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26183.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","code_information":[{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6413.16,"maximum":24023.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18214.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21068.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20167.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19035.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12748.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15283.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6413.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24023.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15966.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23297.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20635.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17590.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8721.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Mcc","code_information":[{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15936.8,"maximum":59699.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45262.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52354.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50117.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47302.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31681.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37978.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15936.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59699.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39677.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57894.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51278.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43712.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21674.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49842.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Cc","code_information":[{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9239.17,"maximum":34610.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26240.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30352.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29055.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27423.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18366.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22017.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9239.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34610.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23002.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33563.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29728.01},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25341.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12565.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28895.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15657.91,"10th_percentile":15657.91,"90th_percentile":15657.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9305.49,"10th_percentile":9305.49,"90th_percentile":9305.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13199.87,"10th_percentile":13199.87,"90th_percentile":13199.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","code_information":[{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7386.28,"maximum":27669.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20977.97},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24265.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23228.15},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21923.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14683.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17602.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7386.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27669.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18389.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26832.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23766.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20259.74},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10045.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23100.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Mcc","code_information":[{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24123.77,"maximum":90368.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":68514.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79250.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75863.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71602.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47956.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57488.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24123.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":90368.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60061.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87636.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77620.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66168.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32808.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75447.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9657.84,"10th_percentile":9657.84,"90th_percentile":9657.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17023.94,"10th_percentile":17023.94,"90th_percentile":17023.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Cc","code_information":[{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12770.86,"maximum":47839.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36270.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41954.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40161.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37905.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25387.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30433.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12770.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47839.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31795.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46393.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41091.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35029.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17368.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39941.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17454.87,"10th_percentile":17454.87,"90th_percentile":17454.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33921.88,"10th_percentile":33921.88,"90th_percentile":33921.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11917.74,"10th_percentile":11917.74,"90th_percentile":11917.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17476.27,"10th_percentile":17476.27,"90th_percentile":17476.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"358","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7676.8,"maximum":28757.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21803.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25219.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24141.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22785.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15260.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18294.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7676.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28757.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19112.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24700.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21056.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10440.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24009.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","code_information":[{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18883.63,"maximum":70738.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53631.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62035.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59384.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56049.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37539.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45000.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18883.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70738.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68600.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60760.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51795.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25681.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59059.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","code_information":[{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13258.52,"maximum":49666.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37655.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43556.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41694.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39353.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26356.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31595.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13258.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49666.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33009.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48165.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42660.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36366.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18031.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41466.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":37375.24,"10th_percentile":37375.24,"90th_percentile":37375.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21089.16,"10th_percentile":21089.16,"90th_percentile":21089.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Mcc","code_information":[{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8742.18,"maximum":32748.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24828.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28719.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27492.11},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25947.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17378.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20833.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8742.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32748.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21765.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31758.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28128.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23978.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11889.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27341.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12956.32,"10th_percentile":12956.32,"90th_percentile":12956.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13192.5,"10th_percentile":13192.5,"90th_percentile":13192.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5492.76,"maximum":20575.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15600.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18044.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17273.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16303.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10919.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13089.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5492.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20575.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13675.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19953.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17673.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15066.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7470.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17178.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4296.78,"10th_percentile":4296.78,"90th_percentile":4296.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13887.39,"10th_percentile":13887.39,"90th_percentile":13887.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders Without Cc/Mcc","code_information":[{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3848.56,"maximum":14416.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10930.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12643.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12102.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11423.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7650.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9171.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3848.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14416.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9581.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13980.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12383.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10556.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5234.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12036.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9737.26,"maximum":36475.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27655.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31988.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30621.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28901.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19356.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23204.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9737.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36475.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24242.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35373.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31330.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26708.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13242.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30453.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":652.3,"10th_percentile":652.3,"90th_percentile":652.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":119593.14,"10th_percentile":119593.14,"90th_percentile":119593.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13551.9,"10th_percentile":13551.9,"90th_percentile":13551.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16114.96,"10th_percentile":16114.96,"90th_percentile":16114.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16495.85,"10th_percentile":16495.85,"90th_percentile":16495.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12230.85,"10th_percentile":12230.85,"90th_percentile":12230.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5606.98,"maximum":21003.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15924.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18419.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17632.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16642.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13361.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5606.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21003.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20368.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18041.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15379.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7625.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17536.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5313.49,"10th_percentile":5313.49,"90th_percentile":5313.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":13022.15,"10th_percentile":13022.15,"90th_percentile":13022.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5403.63,"10th_percentile":5403.63,"90th_percentile":5403.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8029.31,"10th_percentile":8029.31,"90th_percentile":8029.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15504.35,"10th_percentile":15504.35,"90th_percentile":15504.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3994.64,"maximum":14963.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11345.26},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13123.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12562.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11856.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7941.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3994.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14963.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9945.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14511.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10956.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5432.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12493.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4240.04,"10th_percentile":4240.04,"90th_percentile":4240.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Mcc","code_information":[{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11745.02,"maximum":43997.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33357.3},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38584.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36935.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34860.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23348.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27989.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43997.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29241.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42667.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37790.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32215.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15973.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36732.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16809.74,"10th_percentile":16809.74,"90th_percentile":16809.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16352.36,"10th_percentile":16352.36,"90th_percentile":16352.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15561.8,"10th_percentile":15561.8,"90th_percentile":15561.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Cc","code_information":[{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6642.71,"maximum":24883.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18866.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21822.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20889.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19716.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13205.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15830.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6642.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24883.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16538.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24131.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21373.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18220.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9034.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20775.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9516.25,"10th_percentile":9516.25,"90th_percentile":9516.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8128.55,"10th_percentile":8128.55,"90th_percentile":8128.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy Without Cc/Mcc","code_information":[{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5075.94,"maximum":19014.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14416.31},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16675.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15962.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15066.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10090.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12096.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5075.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19014.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12637.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18439.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16332.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13922.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6903.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15875.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10038.76,"maximum":37605.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28511.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32978.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29796.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19956.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10038.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37605.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24993.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36468.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32300.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27535.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13652.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31396.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14105.19,"10th_percentile":14105.19,"90th_percentile":14105.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":30126.18,"10th_percentile":30126.18,"90th_percentile":30126.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28358.47,"10th_percentile":28358.47,"90th_percentile":28358.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14081.59,"10th_percentile":14081.59,"90th_percentile":14081.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14133.19,"10th_percentile":14133.19,"90th_percentile":14133.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8696.72,"10th_percentile":8696.72,"90th_percentile":8696.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13995.24,"10th_percentile":13382.13,"90th_percentile":17131.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14233.1,"10th_percentile":14081.6,"90th_percentile":17006.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5385.68,"maximum":20174.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15295.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17692.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16936.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15985.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10706.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12834.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5385.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20174.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13408.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19564.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17328.97},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14772.28},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7324.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16843.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7635.59,"10th_percentile":7635.59,"90th_percentile":7650.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":12641.5,"10th_percentile":12641.5,"90th_percentile":12641.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16133.11,"10th_percentile":16133.11,"90th_percentile":16133.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5978.54,"10th_percentile":5978.54,"90th_percentile":5978.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10763.1,"10th_percentile":10763.1,"90th_percentile":10763.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7669.99,"10th_percentile":6792.79,"90th_percentile":7681.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5419.71,"10th_percentile":5419.71,"90th_percentile":5419.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":7641.09,"10th_percentile":7031.93,"90th_percentile":7914.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14703.71,"10th_percentile":14703.71,"90th_percentile":14703.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3721.47,"10th_percentile":3721.47,"90th_percentile":3721.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":7647.4,"10th_percentile":5991.58,"90th_percentile":8631.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3461.94,"maximum":12968.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9832.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11373.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10887.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10275.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6882.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8250.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3461.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12968.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8619.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11139.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9495.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4708.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10827.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5110.43,"10th_percentile":5110.43,"90th_percentile":5110.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10775.74,"maximum":40366.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30604.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35400.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33887.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31983.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25679.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10775.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40366.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26828.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39145.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34672.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29556.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14655.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33701.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14903.3,"10th_percentile":14903.3,"90th_percentile":14903.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14925.21,"10th_percentile":14925.21,"90th_percentile":14925.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Cc","code_information":[{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5950.22,"maximum":22289.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16899.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19547.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18712.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17661.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11828.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14179.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5950.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22289.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14814.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21615.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19145.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16320.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8092.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18609.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9041.46,"10th_percentile":9041.46,"90th_percentile":9041.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8434.85,"10th_percentile":8434.85,"90th_percentile":8434.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8182.95,"10th_percentile":8182.95,"90th_percentile":8182.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10124.4,"10th_percentile":10124.4,"90th_percentile":10124.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer Without Cc/Mcc","code_information":[{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4396.63,"maximum":16469.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12486.96},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14443.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13826.36},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13049.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8740.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10477.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4396.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16469.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15971.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14146.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12059.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer With Mcc","code_information":[{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7582.34,"maximum":28403.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21534.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24909.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22505.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15073.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18069.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28403.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18877.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27544.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24396.97},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20797.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10311.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23714.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9369.57,"10th_percentile":9369.57,"90th_percentile":9369.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4694.27,"maximum":17584.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13332.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15421.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14762.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13933.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9331.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11186.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4694.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17584.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11687.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17053.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15104.32},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12875.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6384.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8689.46,"maximum":32550.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24679.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28546.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27326.32},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25791.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17273.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20707.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8689.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32550.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21634.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31566.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27959.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23834.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11817.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27176.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":46128.95,"10th_percentile":46128.95,"90th_percentile":46128.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9168.25,"10th_percentile":9168.25,"90th_percentile":9168.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13332.57,"10th_percentile":13332.57,"90th_percentile":13332.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11216.2,"10th_percentile":11216.2,"90th_percentile":11216.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5361.51,"maximum":20084.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15227.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17613.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16860.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15913.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10658.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12776.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5361.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20084.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19477.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17251.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14706.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7291.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16768.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1232.33,"10th_percentile":1232.33,"90th_percentile":1232.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":29784.71,"10th_percentile":29784.71,"90th_percentile":29784.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Inflammatory Bowel Disease Without Cc/Mcc","code_information":[{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3741.47,"maximum":14015.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10626.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12291.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11766.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11105.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8916.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3741.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14015.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13591.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12038.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10262.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5088.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11701.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8810.92,"10th_percentile":8810.92,"90th_percentile":8810.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8110.09,"maximum":30380.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23033.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26642.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25504.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24071.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16122.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19326.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30380.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29462.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26095.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22245.04},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11029.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25364.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11110.13,"10th_percentile":11110.13,"90th_percentile":11110.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11401.57,"10th_percentile":11401.57,"90th_percentile":13406.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12642.25,"10th_percentile":12642.25,"90th_percentile":12642.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13468.69,"10th_percentile":13468.69,"90th_percentile":13468.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4337.32,"maximum":16247.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12318.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14248.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13639.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12873.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8622.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10336.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4337.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16247.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13955.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11896.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5898.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13565.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4600.49,"10th_percentile":4600.49,"90th_percentile":4600.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6471.81,"10th_percentile":6471.81,"90th_percentile":6471.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12502.56,"10th_percentile":12502.56,"90th_percentile":13067.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6230.23,"10th_percentile":6230.23,"90th_percentile":6230.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6264.21,"10th_percentile":6264.21,"90th_percentile":6264.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":17872.34,"10th_percentile":17872.34,"90th_percentile":17872.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6315.0,"10th_percentile":6050.59,"90th_percentile":7039.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11857.83,"10th_percentile":11857.83,"90th_percentile":11896.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.35,"10th_percentile":128.35,"90th_percentile":128.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6302.41,"10th_percentile":6234.6,"90th_percentile":12112.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5234.13,"10th_percentile":5234.13,"90th_percentile":5234.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2987.47,"maximum":11191.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8484.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9814.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9394.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8867.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5938.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7119.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2987.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11191.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10852.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9612.48},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8194.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4062.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9343.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8534.68,"10th_percentile":8534.68,"90th_percentile":8534.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3674.9,"10th_percentile":3674.9,"90th_percentile":3674.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4500.66,"10th_percentile":4487.66,"90th_percentile":4503.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8242.47,"10th_percentile":8242.47,"90th_percentile":8242.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4523.56,"10th_percentile":4523.56,"90th_percentile":4523.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6965.08,"maximum":26091.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19781.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21903.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20673.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13846.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16598.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6965.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26091.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17340.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25302.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22410.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19104.4},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9472.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21783.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7741.49,"10th_percentile":7741.49,"90th_percentile":7741.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9992.29,"10th_percentile":8995.19,"90th_percentile":11799.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17567.94,"10th_percentile":17567.94,"90th_percentile":17567.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9948.19,"10th_percentile":9948.19,"90th_percentile":9948.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4281.3,"maximum":16037.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12159.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14064.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13463.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12707.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8510.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10202.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4281.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16037.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10659.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15553.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11743.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5822.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13389.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12170.34,"10th_percentile":12170.34,"90th_percentile":12170.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5978.54,"10th_percentile":5978.54,"90th_percentile":5978.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6043.26,"10th_percentile":6043.26,"90th_percentile":6050.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6698.26,"10th_percentile":6698.26,"90th_percentile":6698.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6115.23,"10th_percentile":6115.23,"90th_percentile":6115.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8696.72,"10th_percentile":8696.72,"90th_percentile":8696.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":6124.58,"10th_percentile":6084.47,"90th_percentile":7258.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10668.74,"10th_percentile":10668.74,"90th_percentile":10668.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11637.39,"10th_percentile":9351.61,"90th_percentile":13456.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8127.87,"10th_percentile":8127.87,"90th_percentile":8127.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5370.45,"10th_percentile":280.07,"90th_percentile":6085.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4662.84,"10th_percentile":4662.84,"90th_percentile":4662.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Mcc","code_information":[{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8782.82,"maximum":32900.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24944.28},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28852.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27619.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26068.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17459.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20930.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8782.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32900.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21866.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31906.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28259.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24090.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11944.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27468.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20156.75,"10th_percentile":20156.75,"90th_percentile":20156.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":17484.04,"10th_percentile":17484.04,"90th_percentile":17484.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11717.72,"10th_percentile":11717.72,"90th_percentile":12876.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12836.39,"10th_percentile":12836.39,"90th_percentile":12836.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":33072.76,"10th_percentile":33072.76,"90th_percentile":33072.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15215.2,"10th_percentile":15215.2,"90th_percentile":15215.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11036.89,"10th_percentile":11036.89,"90th_percentile":11036.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5138.55,"maximum":19249.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14594.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16880.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16159.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15251.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10215.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5138.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19249.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12793.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18667.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16533.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14094.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6988.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7290.17,"10th_percentile":7290.17,"90th_percentile":7290.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7451.34,"10th_percentile":7451.34,"90th_percentile":7451.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7296.59,"10th_percentile":7295.67,"90th_percentile":7297.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10696.7,"10th_percentile":10696.7,"90th_percentile":10696.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8132.21,"10th_percentile":8132.21,"90th_percentile":8132.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7245.47,"10th_percentile":7245.47,"90th_percentile":7245.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5841.98,"10th_percentile":5841.98,"90th_percentile":5841.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3564.09,"maximum":13351.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10122.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11708.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11208.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10578.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7085.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3564.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13351.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8873.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12947.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11467.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9775.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4847.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Mcc","code_information":[{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13151.98,"maximum":49267.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37353.26},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41359.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39036.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26145.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31342.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13151.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49267.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32744.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47778.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.88},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36074.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17886.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41133.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8312.18,"maximum":31137.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23607.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27306.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26139.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24671.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16523.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19808.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8312.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31137.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20694.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30196.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26745.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22799.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11304.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25996.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":15976.37,"10th_percentile":15976.37,"90th_percentile":15976.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10076.94,"10th_percentile":10076.94,"90th_percentile":10076.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10165.56,"10th_percentile":10165.56,"90th_percentile":10165.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11682.56,"10th_percentile":11682.56,"90th_percentile":11682.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6286.3,"maximum":23548.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17853.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20651.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19768.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18658.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12496.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14980.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6286.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23548.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15651.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22836.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20226.85},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17242.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8549.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19660.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16782.62,"10th_percentile":16782.62,"90th_percentile":16782.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8703.6,"10th_percentile":8703.6,"90th_percentile":8703.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","code_information":[{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22079.23,"maximum":82709.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62707.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72533.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69434.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65534.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43891.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22079.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82709.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54970.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80208.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71042.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60560.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30027.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69053.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":65742.22,"10th_percentile":65742.22,"90th_percentile":65742.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30029.67,"10th_percentile":30029.67,"90th_percentile":30029.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28656.69,"10th_percentile":28656.69,"90th_percentile":28656.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":58929.47,"10th_percentile":58929.47,"90th_percentile":58929.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Mcc","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30042.14,"maximum":112538.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85323.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98693.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94475.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89169.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59721.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71592.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30042.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112538.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74796.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109136.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96663.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82402.14},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40857.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93957.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Cc","code_information":[{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15926.92,"maximum":59662.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45234.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52322.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50086.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47273.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31661.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37954.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15926.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59662.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39653.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57858.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51246.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43685.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21660.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49811.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","code_information":[{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12189.29,"maximum":45661.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34619.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40043.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38332.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36179.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24231.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29047.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12189.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45661.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30347.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44281.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39220.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33433.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16577.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38122.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","code_information":[{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19581.07,"maximum":73351.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55612.66},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64326.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61577.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58119.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38925.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46663.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19581.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73351.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48751.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71133.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63004.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53708.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26630.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61240.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","code_information":[{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11957.0,"maximum":44791.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33959.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39280.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37601.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35489.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23769.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28494.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11957.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44791.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29769.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43437.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38472.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32796.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16261.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37395.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","code_information":[{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8719.11,"maximum":32661.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24763.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28643.7},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27419.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25879.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17332.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20778.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8719.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32661.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21708.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31674.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28054.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23915.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11857.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27269.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5291.07,"10th_percentile":5291.07,"90th_percentile":5291.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Mcc","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18140.61,"maximum":67955.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51521.57},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59594.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57047.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53843.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36062.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43230.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18140.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67955.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45164.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65900.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58369.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49757.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24671.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56735.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Cc","code_information":[{"code":"412","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11546.22,"maximum":43252.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32792.69},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36310.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34270.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22952.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27515.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11546.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43252.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28746.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41944.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37151.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31669.96},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15702.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36111.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. Without Cc/Mcc","code_information":[{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9118.91,"maximum":34159.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25898.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29957.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28676.84},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18127.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21730.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9118.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34159.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22703.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33126.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29341.04},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25012.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12401.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28519.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19564.6,"maximum":73289.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55565.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64272.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61526.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58070.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38892.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46623.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19564.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73289.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48710.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71073.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62951.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53663.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26607.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61188.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","code_information":[{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11349.62,"maximum":42515.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32234.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37285.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35691.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33687.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22562.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27046.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11349.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42515.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28257.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41230.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36518.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31130.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15435.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35496.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17610.32,"10th_percentile":17610.32,"90th_percentile":17610.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","code_information":[{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7486.78,"maximum":28045.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21263.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24595.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23544.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22221.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14883.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17841.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7486.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28045.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18639.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27197.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24089.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20535.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10182.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23415.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13105.3,"maximum":49092.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37220.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43053.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41213.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38898.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26052.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31230.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13105.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49092.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32628.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.69},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35946.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17823.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40987.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":39088.85,"10th_percentile":39088.85,"90th_percentile":39088.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18965.46,"10th_percentile":18965.46,"90th_percentile":18965.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22218.1,"10th_percentile":22218.1,"90th_percentile":22218.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35597.22,"10th_percentile":35597.22,"90th_percentile":35597.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10226.44,"10th_percentile":10226.44,"90th_percentile":10226.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","code_information":[{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9289.7,"maximum":34799.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26383.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30518.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29213.93},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27573.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18467.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22137.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9289.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34799.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23128.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33747.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29890.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25480.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12633.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29053.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":25866.06,"10th_percentile":25866.06,"90th_percentile":25866.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13439.78,"10th_percentile":13439.78,"90th_percentile":13439.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13355.47,"10th_percentile":12270.56,"90th_percentile":13445.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10335.55,"10th_percentile":10335.55,"90th_percentile":10335.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24733.38,"10th_percentile":22502.81,"90th_percentile":24967.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":91.96,"10th_percentile":91.96,"90th_percentile":91.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13471.48,"10th_percentile":13471.48,"90th_percentile":13471.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","code_information":[{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7500.51,"maximum":28097.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21302.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24640.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23587.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22262.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14910.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17874.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7500.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28097.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18674.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27247.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.69},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.05},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10200.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23458.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10141.97,"10th_percentile":10141.97,"90th_percentile":10141.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10218.14,"10th_percentile":10218.14,"90th_percentile":10218.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":27105.48,"10th_percentile":27105.48,"90th_percentile":27105.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":3213.09,"10th_percentile":3213.09,"90th_percentile":3213.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8501.0,"10th_percentile":8501.0,"90th_percentile":8501.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Mcc","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18710.64,"maximum":70090.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53140.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58840.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55535.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37195.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44588.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18710.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70090.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46583.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67971.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60203.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51321.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25446.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58518.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Cc","code_information":[{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9541.76,"maximum":35743.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27099.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31346.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30006.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28321.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22738.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9541.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35743.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23756.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34663.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30701.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26171.96},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12976.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29842.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15008.23,"10th_percentile":15008.23,"90th_percentile":15008.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7685.58,"maximum":28790.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21828.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25248.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24169.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22811.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15278.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18315.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7685.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28790.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19134.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27920.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24729.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21080.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10452.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22806.87,"maximum":85434.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64774.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74924.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71722.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67693.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45338.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54350.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85434.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56782.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82852.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73383.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62556.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31017.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71329.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":56547.54,"10th_percentile":56547.54,"90th_percentile":56547.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12015.21,"maximum":45009.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34124.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39471.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37785.03},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35662.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23885.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12015.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45009.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29914.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43648.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38660.19},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32956.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16340.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37577.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17683.69,"10th_percentile":17683.69,"90th_percentile":17683.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","code_information":[{"code":"425","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8239.14,"maximum":30863.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23400.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25910.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24454.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16378.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19634.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8239.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30863.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20513.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29930.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26510.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22599.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11205.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25768.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","code_information":[{"code":"426","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60524.71,"maximum":226726.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":171897.66},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198833.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190336.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179645.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120318.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144234.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60524.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":226726.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150688.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219872.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194744.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":166012.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82313.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189292.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","code_information":[{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39642.11,"maximum":148500.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112588.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130230.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124665.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":117663.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78805.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94469.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39642.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":148500.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98697.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144011.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127552.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108733.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53913.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123981.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":102079.52,"10th_percentile":102079.52,"90th_percentile":102079.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":91587.7,"10th_percentile":91587.7,"90th_percentile":91587.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":55036.44,"10th_percentile":55036.44,"90th_percentile":55036.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":108190.14,"10th_percentile":108190.14,"90th_percentile":108190.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","code_information":[{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30874.12,"maximum":115655.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87686.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101426.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97091.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91638.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61375.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73575.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30874.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":115655.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76867.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112158.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99340.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84684.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41988.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96559.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":52315.43,"10th_percentile":52315.43,"90th_percentile":52315.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":42276.1,"10th_percentile":42276.1,"90th_percentile":42514.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","code_information":[{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49477.68,"maximum":185344.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":140522.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162542.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155595.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146856.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98357.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117908.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49477.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":185344.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123184.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179741.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159199.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135711.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67289.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154743.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","code_information":[{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31670.96,"maximum":118639.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":89949.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104044.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99597.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94003.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62959.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75474.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31670.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":118639.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78851.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115053.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101904.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86869.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43072.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99051.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10808.69,"maximum":40489.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30698.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35508.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32081.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21486.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25757.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10808.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40489.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26910.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39265.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34778.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29647.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14699.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33804.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7837.9,"10th_percentile":7837.9,"90th_percentile":18765.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8085.72,"10th_percentile":8085.72,"90th_percentile":8085.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17902.66,"10th_percentile":17902.66,"90th_percentile":17902.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14633.82,"10th_percentile":14633.82,"90th_percentile":14633.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8357.1,"10th_percentile":8357.1,"90th_percentile":8357.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8774.96,"10th_percentile":8774.96,"90th_percentile":8774.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14094.82,"10th_percentile":14094.82,"90th_percentile":15656.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26786.01,"10th_percentile":26786.01,"90th_percentile":26786.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":23235.34,"10th_percentile":23235.34,"90th_percentile":23235.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18412.08,"10th_percentile":18412.08,"90th_percentile":18412.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14178.0,"10th_percentile":14178.0,"90th_percentile":14178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5800.29,"maximum":21728.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16473.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19054.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18240.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11530.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13822.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5800.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21728.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14441.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21071.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15909.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7888.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18140.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5187.57,"10th_percentile":5187.57,"90th_percentile":5187.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8045.06,"10th_percentile":8045.06,"90th_percentile":8045.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8490.01,"10th_percentile":8490.01,"90th_percentile":8490.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8301.87,"10th_percentile":8301.87,"90th_percentile":8301.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":11519.86,"10th_percentile":11519.86,"90th_percentile":11519.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12123.4,"10th_percentile":12123.4,"90th_percentile":12123.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8357.1,"10th_percentile":8357.1,"90th_percentile":8357.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3912.81,"maximum":14657.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11112.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12854.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12304.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11613.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7778.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9324.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3912.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14657.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9741.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14214.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12589.88},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10732.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5321.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12237.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10086.53,"maximum":37784.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28647.01},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33135.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31719.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29938.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20051.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10086.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37784.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25112.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36642.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32454.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27666.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13717.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31545.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14136.65,"10th_percentile":14136.65,"90th_percentile":14136.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12911.05,"10th_percentile":12911.05,"90th_percentile":14127.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","code_information":[{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6211.62,"maximum":23268.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17641.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20406.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19534.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18436.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12348.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14802.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6211.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23268.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15465.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22565.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17037.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8447.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19427.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7134.45,"10th_percentile":7134.45,"90th_percentile":7134.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8755.81,"10th_percentile":8755.81,"90th_percentile":8755.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","code_information":[{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4686.04,"maximum":17553.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13308.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15394.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14736.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13908.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4686.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17553.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11666.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17023.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15077.81},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14655.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Mcc","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8952.51,"maximum":33536.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25426.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29410.44},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28153.55},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26572.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17796.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21334.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8952.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33536.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22289.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32522.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24555.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12175.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27999.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12994.91,"10th_percentile":12994.91,"90th_percentile":12994.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12885.01,"10th_percentile":12885.01,"90th_percentile":12885.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12837.3,"10th_percentile":12837.3,"90th_percentile":12837.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4619.59,"maximum":17305.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13120.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15176.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14527.52},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13711.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9183.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11008.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4619.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17305.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11501.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16781.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14864.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12671.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6282.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14447.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12891.37,"10th_percentile":12891.37,"90th_percentile":12902.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6138.67,"10th_percentile":6138.67,"90th_percentile":6674.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10570.35,"10th_percentile":10570.35,"90th_percentile":12346.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3928.71,"10th_percentile":3928.71,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6540.38,"10th_percentile":5866.01,"90th_percentile":6662.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6404.72,"10th_percentile":6404.72,"90th_percentile":6404.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3412.52,"maximum":12783.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9691.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11210.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10731.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10128.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6783.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8132.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3412.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12783.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8496.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12396.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10980.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9360.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4641.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3330.71,"10th_percentile":3330.71,"90th_percentile":3330.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":12653.75,"10th_percentile":12653.75,"90th_percentile":12653.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8895.24,"10th_percentile":8895.24,"90th_percentile":8895.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3928.71,"10th_percentile":3928.71,"90th_percentile":3928.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9855.88,"maximum":36920.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27991.94},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32378.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30994.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29253.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19592.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23487.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9855.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36920.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24538.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35804.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31712.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13404.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30824.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":25028.48,"10th_percentile":25028.48,"90th_percentile":25028.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13414.82,"10th_percentile":13414.82,"90th_percentile":13414.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15481.5,"10th_percentile":15481.5,"90th_percentile":15481.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5301.1,"maximum":19858.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15055.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17414.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16670.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15734.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10538.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12632.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5301.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19858.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13198.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19257.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17056.85},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14540.31},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7209.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16579.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5314.7,"10th_percentile":5314.7,"90th_percentile":5314.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7495.54,"10th_percentile":7495.54,"90th_percentile":7500.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5407.56,"10th_percentile":5407.56,"90th_percentile":5407.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7494.03,"10th_percentile":7494.03,"90th_percentile":7494.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14409.0,"10th_percentile":14409.0,"90th_percentile":14409.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3842.51,"maximum":14394.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10913.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12623.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12083.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11405.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7638.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9156.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3842.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14394.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9566.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12363.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10539.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12017.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5459.47,"10th_percentile":5459.47,"90th_percentile":5459.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Mcc","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9176.02,"maximum":34373.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26061.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30144.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28856.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27235.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18241.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21867.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9176.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34373.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22845.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33334.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29524.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25168.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12479.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28698.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13061.83,"10th_percentile":13045.33,"90th_percentile":15545.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11726.9,"10th_percentile":11726.9,"90th_percentile":11726.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6010.07,"maximum":22513.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17069.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19744.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18900.29},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17838.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11947.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14322.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6010.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22513.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14963.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21833.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19338.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16484.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8173.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18796.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8436.85,"10th_percentile":8436.85,"90th_percentile":8436.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8422.44,"10th_percentile":8422.44,"90th_percentile":8422.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8428.92,"10th_percentile":8428.92,"90th_percentile":8428.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25238.5,"10th_percentile":25238.5,"90th_percentile":25238.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16113.65,"10th_percentile":16113.65,"90th_percentile":16113.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9325.58,"10th_percentile":9325.58,"90th_percentile":9325.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract Without Cc/Mcc","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4543.25,"maximum":17019.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12903.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14925.32},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14287.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13484.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9031.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10826.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4543.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17019.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11311.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16504.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14618.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12461.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6178.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14209.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6245.18,"10th_percentile":6245.18,"90th_percentile":6245.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":14309.09,"10th_percentile":14309.09,"90th_percentile":14309.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8920.25,"10th_percentile":8920.25,"90th_percentile":8920.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","code_information":[{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36693.09,"maximum":137452.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104212.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120542.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115391.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108910.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72943.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87442.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36693.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":137452.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91354.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133297.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118063.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100644.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49902.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114758.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23289.04,"maximum":87241.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66143.76},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76508.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73238.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69125.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46296.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55499.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23289.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87241.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57982.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84603.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74934.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63879.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31673.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72837.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31431.92,"10th_percentile":31431.92,"90th_percentile":31431.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36825.58,"10th_percentile":31646.26,"90th_percentile":39530.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":50490.31,"10th_percentile":50490.31,"90th_percentile":50490.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31625.87,"10th_percentile":31625.87,"90th_percentile":31625.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29268.36,"maximum":109639.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":83125.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96151.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92042.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86872.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58183.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69748.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29268.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":109639.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72869.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106325.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94174.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80279.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39804.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91537.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17740.27,"maximum":66455.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50384.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58279.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55789.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52655.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35266.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42276.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17740.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66455.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44168.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64446.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57081.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48659.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24126.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55483.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23497.72,"10th_percentile":23497.72,"90th_percentile":23497.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":48132.34,"10th_percentile":48132.34,"90th_percentile":48132.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19660.91,"10th_percentile":19660.91,"90th_percentile":19660.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23916.93,"10th_percentile":23916.93,"90th_percentile":23916.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":46484.42,"10th_percentile":46484.42,"90th_percentile":46484.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23232.41,"10th_percentile":23232.41,"90th_percentile":23232.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46148.63,"maximum":172873.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":131067.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":151605.74},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145126.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136975.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91739.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109975.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46148.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":172873.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114896.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167647.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148488.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126580.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62762.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144331.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32747.33,"maximum":122672.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93006.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107580.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102982.74},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97198.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65099.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78039.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32747.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":122672.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81531.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118963.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105367.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89822.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44536.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102418.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":36842.08,"10th_percentile":36842.08,"90th_percentile":36842.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":47413.37,"10th_percentile":47413.37,"90th_percentile":47413.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"458","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22914.51,"maximum":85838.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65080.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75277.88},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72060.8},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68013.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45552.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54606.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22914.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85838.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57050.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83243.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73729.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62851.87},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31163.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71665.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":69035.67,"10th_percentile":69035.67,"90th_percentile":69035.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","code_information":[{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30330.45,"maximum":113618.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86142.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99640.44},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95382.21},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90024.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60294.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72279.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30330.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":113618.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75513.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110183.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97591.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83192.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41249.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94859.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","code_information":[{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14607.82,"maximum":54721.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41488.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47989.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45938.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43358.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29039.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34811.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14607.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54721.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36369.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53067.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47002.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40067.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19866.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45686.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31299.73,"maximum":117249.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88895.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102824.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98430.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92901.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62221.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74589.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31299.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":117249.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77927.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113705.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100710.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85851.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42567.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97890.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17104.88,"maximum":64075.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48579.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56192.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53790.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50769.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34003.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40762.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17104.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64075.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42586.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62138.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55036.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46916.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23262.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53496.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10015.15,"maximum":37516.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10015.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13620.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28586.3,"maximum":107084.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81188.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93910.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89897.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84848.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56827.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68123.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28586.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":107084.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71171.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103847.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91979.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78408.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38877.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89404.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Cc","code_information":[{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19366.9,"maximum":72548.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55004.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63623.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60904.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57483.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46152.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19366.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72548.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48217.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70355.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62315.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53121.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26338.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60570.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":71166.23,"10th_percentile":71166.23,"90th_percentile":71166.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15091.09,"maximum":56531.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42860.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49576.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47457.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44792.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29999.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35963.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15091.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56531.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37572.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54822.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48557.16},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41393.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20523.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47197.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16657.31,"maximum":62398.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47308.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54721.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52383.36},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49441.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33113.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16657.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62398.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41471.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60512.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53596.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45689.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22653.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52096.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25315.4,"10th_percentile":25315.4,"90th_percentile":25315.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10592.86,"maximum":39681.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30085.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34799.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33312.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31441.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21057.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25243.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10592.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39681.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26373.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38481.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34083.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29055.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14406.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33129.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12960.32,"10th_percentile":12960.32,"90th_percentile":12960.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14602.8,"10th_percentile":14602.8,"90th_percentile":14602.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14615.4,"10th_percentile":14243.75,"90th_percentile":15330.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":37658.49,"10th_percentile":37658.49,"90th_percentile":37658.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":28401.29,"10th_percentile":28401.29,"90th_percentile":28401.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14610.11,"10th_percentile":14602.81,"90th_percentile":14626.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Mcc","code_information":[{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26517.58,"maximum":99335.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75313.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87114.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83391.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78707.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52714.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63193.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26517.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":99335.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66020.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96332.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85323.13},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72734.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36063.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82934.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Cc","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16178.98,"maximum":60606.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45950.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53150.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50879.15},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48021.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32162.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38555.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16178.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60606.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40280.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58774.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52057.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44377.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22003.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50600.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22438.21,"10th_percentile":22438.21,"90th_percentile":22438.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26487.52,"10th_percentile":26487.52,"90th_percentile":26487.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27346.58,"10th_percentile":27346.58,"90th_percentile":27346.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion Without Cc/Mcc","code_information":[{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13406.8,"maximum":50222.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38076.96},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44043.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42161.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39793.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26651.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50222.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33378.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48703.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43137.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36773.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18233.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41930.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","code_information":[{"code":"474","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23575.16,"maximum":88312.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66956.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77448.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74138.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69974.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46865.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56181.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23575.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88312.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58695.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85643.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75855.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64663.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32062.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73732.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","code_information":[{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12497.38,"maximum":46815.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35494.09},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41055.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39301.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37093.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24843.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29782.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12497.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46815.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31114.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45400.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40211.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34278.87},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16996.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39085.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19211.7,"10th_percentile":19211.7,"90th_percentile":19211.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6481.26,"maximum":24278.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18407.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21291.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20382.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19237.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12884.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6481.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24278.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23544.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.13},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17777.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8814.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20270.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"477","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18971.5,"maximum":71067.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53881.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62324.44},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59660.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37713.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45210.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18971.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71067.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47233.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68919.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61042.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52036.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25801.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59333.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":280.07,"10th_percentile":280.07,"90th_percentile":280.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13505.09,"maximum":50590.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38356.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44366.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42470.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40084.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26847.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32183.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13505.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50590.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33623.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49061.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43454.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37042.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18366.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42237.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16971.89,"10th_percentile":16971.89,"90th_percentile":16971.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17543.73,"10th_percentile":17543.73,"90th_percentile":17543.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"479","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10208.45,"maximum":38241.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10208.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13883.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15993.37,"maximum":59911.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45423.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52540.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50295.42},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31793.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38113.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15993.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59911.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39818.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58100.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51460.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43867.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21750.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50019.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22100.43,"10th_percentile":22100.43,"90th_percentile":22100.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21571.67,"10th_percentile":20973.88,"90th_percentile":25958.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11502.28,"maximum":43087.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32667.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37786.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36172.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34140.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22865.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27410.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11502.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43087.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28637.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41785.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37009.82},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31549.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15643.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35973.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16610.66,"10th_percentile":16610.66,"90th_percentile":16610.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16035.0,"10th_percentile":16035.0,"90th_percentile":16035.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18138.42,"10th_percentile":16069.66,"90th_percentile":18633.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16101.17,"10th_percentile":16031.19,"90th_percentile":19530.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16035.69,"10th_percentile":16035.69,"90th_percentile":16035.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8956.9,"maximum":33552.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25438.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28167.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26585.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17805.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21344.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8956.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33552.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22300.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32538.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28819.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24567.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12181.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28013.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12302.84,"10th_percentile":12302.84,"90th_percentile":12302.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15195.82,"10th_percentile":15195.82,"90th_percentile":15195.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11668.24,"10th_percentile":11668.24,"90th_percentile":11668.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10906.81,"10th_percentile":10906.81,"90th_percentile":10906.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15222.34,"maximum":57023.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43233.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50007.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47870.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45181.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30260.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36275.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15222.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57023.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37899.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55299.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.47},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41753.13},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20702.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19747.09,"10th_percentile":19747.09,"90th_percentile":19747.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18266.76,"10th_percentile":18266.76,"90th_percentile":18266.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19618.76,"10th_percentile":19618.76,"90th_percentile":19618.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":51307.41,"10th_percentile":51307.41,"90th_percentile":51307.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Mcc","code_information":[{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17722.14,"maximum":66387.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50333.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58220.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55732.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52601.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35230.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42233.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17722.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66387.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44122.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64380.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57022.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48609.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55426.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","code_information":[{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11483.62,"maximum":43017.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32614.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37725.54},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36113.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34084.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22828.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27366.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11483.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43017.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28590.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41717.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36949.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31498.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15617.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35915.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8601.04,"maximum":32219.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24428.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28255.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27048.27},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25529.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17098.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20496.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8601.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32219.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21414.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31245.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27674.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23591.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11697.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26900.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9714.2,"maximum":36389.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27589.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31912.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30548.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28833.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19311.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23149.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9714.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36389.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24185.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35289.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31256.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26644.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13211.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30381.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6133.09,"maximum":22974.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6133.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8341.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20163.19,"maximum":75531.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57265.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66239.34},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63408.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59847.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40082.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48050.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20163.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75531.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50200.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73248.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64877.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55305.31},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27421.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63061.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13927.4,"maximum":52172.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39555.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45753.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43798.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41338.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27686.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33189.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13927.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52172.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34675.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50595.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44812.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38201.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18941.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43558.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13139.81,"10th_percentile":13139.81,"90th_percentile":13139.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18407.22,"10th_percentile":18407.22,"90th_percentile":18407.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13139.81,"10th_percentile":13139.81,"90th_percentile":13139.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17664.79,"10th_percentile":17664.79,"90th_percentile":17664.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","code_information":[{"code":"494","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11019.02,"maximum":41277.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31295.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36199.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34652.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32705.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21904.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26259.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41277.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27434.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40029.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35454.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30223.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14985.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34462.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18718.83,"10th_percentile":18718.83,"90th_percentile":18718.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14620.93,"10th_percentile":14620.93,"90th_percentile":14620.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5092.6,"10th_percentile":5092.6,"90th_percentile":5092.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13847.95,"10th_percentile":13847.95,"90th_percentile":13847.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","code_information":[{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19911.12,"maximum":74587.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56550.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65411.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62615.84},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59098.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39581.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47449.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19911.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74587.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49572.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72332.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64066.12},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54613.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27079.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62272.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26233.85,"10th_percentile":26233.85,"90th_percentile":26233.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","code_information":[{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9906.41,"maximum":37109.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28135.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32544.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31153.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29403.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19693.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23607.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37109.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24664.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35987.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31874.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27172.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13472.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30982.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15285.97,"10th_percentile":15285.97,"90th_percentile":15285.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13320.47,"10th_percentile":13320.47,"90th_percentile":13320.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","code_information":[{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6635.57,"maximum":24856.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18845.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21798.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20867.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19695.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13191.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15813.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6635.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24856.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16520.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18200.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9024.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20752.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16567.24,"maximum":62061.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47053.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54426.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52100.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49173.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32934.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39480.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16567.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62061.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41247.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60185.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53306.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45442.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22531.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51814.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","code_information":[{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11064.6,"maximum":41448.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31424.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36349.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34795.6},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32841.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21995.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11064.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41448.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27547.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40195.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35601.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30348.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15047.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34604.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Mcc","code_information":[{"code":"500","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17380.01,"maximum":65105.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49361.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57096.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51586.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34550.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41417.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17380.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65105.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43271.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63137.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55922.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47671.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23636.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54356.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24575.04,"10th_percentile":24575.04,"90th_percentile":24575.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Cc","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9599.98,"maximum":35961.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27265.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31537.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30189.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28494.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22877.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9599.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35961.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23901.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34874.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30888.93},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26331.63},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13055.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":25349.31,"10th_percentile":25349.31,"90th_percentile":25349.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13561.44,"10th_percentile":13561.44,"90th_percentile":13561.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":22256.75,"10th_percentile":22256.75,"90th_percentile":22256.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13759.38,"10th_percentile":13759.38,"90th_percentile":13759.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures Without Cc/Mcc","code_information":[{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7391.23,"maximum":27687.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20992.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24281.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23243.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21938.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14693.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17613.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7391.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27687.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18401.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26850.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23782.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20273.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10052.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23116.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Mcc","code_information":[{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15327.78,"maximum":57418.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43532.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50354.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48202.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45494.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36527.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15327.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57418.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38161.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55682.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49318.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42042.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20845.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47938.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12654.85,"10th_percentile":12654.85,"90th_percentile":12654.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10265.02,"maximum":38452.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29153.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33722.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32281.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30467.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20406.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10265.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38452.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25556.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37290.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33028.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28155.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13960.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32104.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures Without Cc/Mcc","code_information":[{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9845.45,"maximum":36881.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27962.3},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32343.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30961.66},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29222.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19572.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23462.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9845.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36881.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24512.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35766.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31678.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27004.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13389.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30791.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7409.35,"maximum":27755.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21043.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24340.92},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23300.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21991.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14729.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7409.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27755.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26916.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23840.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20323.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10076.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23172.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11632.22,"10th_percentile":11632.22,"90th_percentile":11632.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","code_information":[{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9920.14,"maximum":37161.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28174.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32589.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31196.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29444.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19720.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23640.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9920.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37161.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24698.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36037.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31919.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27209.8},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13491.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31025.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","code_information":[{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8316.57,"maximum":31154.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23620.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27321.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26153.69},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24684.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16532.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19818.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8316.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31154.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20705.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30212.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26759.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22811.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11310.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26010.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9696.96,"10th_percentile":9696.96,"90th_percentile":9696.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","code_information":[{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16587.56,"maximum":62137.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47110.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54492.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52164.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49234.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32974.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39529.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16587.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62137.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41298.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60258.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53372.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45497.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22559.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51878.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21008.7,"10th_percentile":21008.7,"90th_percentile":21008.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","code_information":[{"code":"511","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11419.36,"maximum":42777.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32432.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37514.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35911.24},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33894.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27213.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11419.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42777.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28430.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41484.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36743.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15530.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35714.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15367.59,"10th_percentile":15367.59,"90th_percentile":15367.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","code_information":[{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9090.9,"maximum":34054.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25819.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29865.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28588.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26983.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21664.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9090.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34054.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22633.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33025.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29250.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24935.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12363.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28432.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","code_information":[{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8645.52,"maximum":32386.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24554.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28401.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27188.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25661.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17186.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8645.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32386.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21524.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31407.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27817.88},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23713.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11757.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27039.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","code_information":[{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5614.12,"maximum":21030.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15944.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18443.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17655.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16663.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11160.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13378.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5614.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21030.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13977.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20394.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18064.04},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15398.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7635.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17558.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","code_information":[{"code":"515","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17501.38,"maximum":65560.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49706.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57494.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55037.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51946.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34791.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41706.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17501.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65560.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43573.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63578.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56312.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48004.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23801.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54736.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24950.17,"10th_percentile":24950.17,"90th_percentile":24950.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","code_information":[{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11412.22,"maximum":42750.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32412.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37491.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35888.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33873.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22686.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27196.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11412.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42750.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28413.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41458.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36720.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31302.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15520.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35692.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18909.31,"10th_percentile":18909.31,"90th_percentile":18909.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15613.2,"10th_percentile":15613.2,"90th_percentile":15613.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","code_information":[{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8439.04,"maximum":31612.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23967.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27723.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25048.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16776.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20110.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8439.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31612.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21010.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30657.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27153.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.31},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26393.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11593.65,"10th_percentile":11593.65,"90th_percentile":11593.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","code_information":[{"code":"518","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20523.99,"maximum":76883.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58290.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67424.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64543.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60917.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40800.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48910.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20523.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76883.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51098.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74559.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66038.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56294.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27912.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64189.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29725.86,"10th_percentile":29725.86,"90th_percentile":34813.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":74315.11,"10th_percentile":74315.11,"90th_percentile":74315.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Cc","code_information":[{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10984.42,"maximum":41147.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31197.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36085.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34543.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32603.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21836.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10984.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41147.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27347.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39903.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35343.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30129.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14938.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34354.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17800.13,"10th_percentile":17800.13,"90th_percentile":17800.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11727.94,"10th_percentile":11727.94,"90th_percentile":11727.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","code_information":[{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8204.0,"maximum":30732.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23300.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26951.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25799.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24350.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16308.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19550.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8203.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30732.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29803.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26397.21},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22502.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11157.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25658.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":49693.98,"10th_percentile":49693.98,"90th_percentile":49693.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":15250.74,"10th_percentile":15250.74,"90th_percentile":15250.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","code_information":[{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15762.16,"maximum":59045.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44766.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51781.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49568.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46784.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31333.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37562.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15762.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59045.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39243.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57260.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50716.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43233.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21436.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49296.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20853.95,"10th_percentile":20853.95,"90th_percentile":20853.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22606.74,"10th_percentile":22563.91,"90th_percentile":25159.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22546.41,"10th_percentile":22546.41,"90th_percentile":22546.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":62447.3,"10th_percentile":62447.3,"90th_percentile":62447.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","code_information":[{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11629.7,"maximum":43565.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33029.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38205.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36572.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34518.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27714.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11629.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43565.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28954.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42248.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37419.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31898.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15816.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36372.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16356.3,"10th_percentile":16356.3,"90th_percentile":19802.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16326.8,"10th_percentile":16241.67,"90th_percentile":16343.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16364.6,"10th_percentile":16326.8,"90th_percentile":19551.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":31754.31,"10th_percentile":31754.31,"90th_percentile":31754.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16350.5,"10th_percentile":16350.5,"90th_percentile":19738.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur With Mcc","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8609.28,"maximum":32250.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24451.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28282.88},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27074.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25553.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17114.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20516.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8609.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32250.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21434.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31275.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27701.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23614.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11708.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26925.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur Without Mcc","code_information":[{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4426.83,"maximum":16582.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12572.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14542.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13921.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13139.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8800.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10549.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4426.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16582.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11021.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16081.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14243.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12142.28},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6020.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13845.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis With Mcc","code_information":[{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7040.31,"maximum":26373.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19995.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23128.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22140.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20896.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13995.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16777.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7040.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26373.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17528.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22652.94},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19310.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9574.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22018.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8158.5,"10th_percentile":8158.5,"90th_percentile":8158.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10302.98,"10th_percentile":10302.98,"90th_percentile":10302.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10321.7,"10th_percentile":10321.7,"90th_percentile":10321.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4435.06,"maximum":16613.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12596.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14569.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13947.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13163.88},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8816.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10569.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4435.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16613.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11042.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14270.29},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6031.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13870.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6152.13,"10th_percentile":6152.13,"90th_percentile":6152.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5886.63,"10th_percentile":5886.63,"90th_percentile":6331.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5240.69,"maximum":19631.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14884.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16480.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15555.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10418.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12488.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5240.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19631.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13047.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19038.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16862.48},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14374.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7127.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16390.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3955.64,"maximum":14817.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11234.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12994.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12439.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11740.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7863.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9426.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3955.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14817.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9848.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14369.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12727.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10849.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5379.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12371.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Mcc","code_information":[{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10816.93,"maximum":40520.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30721.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35535.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34016.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32106.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21503.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25777.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10816.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40520.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26930.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39295.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34804.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14711.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33830.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14860.69,"10th_percentile":14860.69,"90th_percentile":14860.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Cc","code_information":[{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7118.84,"maximum":26667.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7118.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis Without Cc/Mcc","code_information":[{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4324.13,"maximum":16198.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12281.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14205.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13598.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12834.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8596.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10304.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4324.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16198.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10765.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15708.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13913.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11860.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5880.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","code_information":[{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9701.02,"maximum":36340.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27552.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31869.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30507.46},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28793.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19284.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9701.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36340.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24152.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35241.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31214.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26608.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13193.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30340.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":29089.96,"10th_percentile":29089.96,"90th_percentile":29089.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":11520.3,"10th_percentile":11520.3,"90th_percentile":11520.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12798.5,"10th_percentile":12798.5,"90th_percentile":12798.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14444.82,"10th_percentile":14444.82,"90th_percentile":14444.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14455.82,"10th_percentile":14455.82,"90th_percentile":14455.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":26608.79,"10th_percentile":26608.79,"90th_percentile":26608.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5645.43,"maximum":21147.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16033.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18546.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17753.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16756.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11222.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13453.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5645.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21147.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14055.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20508.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18164.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15484.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7677.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7526.06,"10th_percentile":7526.06,"90th_percentile":7526.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16546.86,"10th_percentile":16546.86,"90th_percentile":16546.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7667.14,"10th_percentile":7667.14,"90th_percentile":7667.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7453.06,"10th_percentile":7453.06,"90th_percentile":8197.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8227.46,"10th_percentile":8180.56,"90th_percentile":8882.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":498.62,"10th_percentile":498.62,"90th_percentile":498.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8142.14,"10th_percentile":8142.14,"90th_percentile":8256.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4144.0,"maximum":15523.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11769.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13613.74},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13031.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12299.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8237.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9875.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15523.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10317.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15054.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13333.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11366.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5635.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12960.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Mcc","code_information":[{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13628.66,"maximum":51053.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38707.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42858.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40451.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27092.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32478.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13628.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51053.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33931.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49509.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43851.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37381.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18534.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42624.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34549.32,"10th_percentile":34549.32,"90th_percentile":34549.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6334.08,"maximum":23727.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17989.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20808.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19919.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18800.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12591.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15094.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6334.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23727.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23010.33},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.58},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17373.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8614.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19810.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8966.15,"10th_percentile":8966.15,"90th_percentile":8966.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7323.68,"10th_percentile":7323.68,"90th_percentile":7323.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7284.47,"10th_percentile":7284.47,"90th_percentile":7284.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4592.13,"maximum":17202.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13042.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15085.88},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13630.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9128.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10943.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4592.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17202.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11433.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16682.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14775.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12595.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6245.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14362.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Mcc","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10603.85,"maximum":39722.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30116.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34835.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33346.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31473.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21079.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25269.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10603.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39722.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26400.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38521.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34119.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29085.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14421.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33163.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6629.54,"maximum":24834.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18828.7},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21779.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20848.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19677.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13179.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15798.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6629.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24834.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16505.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24083.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21331.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18184.05},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9016.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20734.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis Without Cc/Mcc","code_information":[{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4800.26,"maximum":17981.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13633.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15769.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15095.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14247.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9542.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11439.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4800.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17981.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13166.57},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6528.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15012.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9204.58,"maximum":34480.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26142.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30238.52},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28946.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27320.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18297.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21935.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9204.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34480.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22916.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33438.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29616.69},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25247.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12518.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28787.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13239.32,"10th_percentile":13239.32,"90th_percentile":13239.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11074.42,"10th_percentile":11074.42,"90th_percentile":11074.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12828.21,"10th_percentile":12828.21,"90th_percentile":12828.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13231.53,"10th_percentile":13231.53,"90th_percentile":13231.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5279.14,"maximum":19775.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14993.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17342.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16601.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15669.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10494.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12580.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5279.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19775.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13143.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19177.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16986.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14480.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7179.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16510.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":138.2,"10th_percentile":138.2,"90th_percentile":138.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6810.95,"10th_percentile":6810.95,"90th_percentile":6810.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7533.67,"10th_percentile":7533.67,"90th_percentile":7533.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5481.98,"10th_percentile":5481.98,"90th_percentile":5481.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7478.04,"10th_percentile":7478.04,"90th_percentile":7545.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10091.15,"10th_percentile":10091.15,"90th_percentile":10091.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13041.2,"10th_percentile":13041.2,"90th_percentile":14480.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6309.95,"10th_percentile":6309.95,"90th_percentile":6309.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6767.45,"10th_percentile":1317.34,"90th_percentile":7493.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6361.23,"10th_percentile":6361.23,"90th_percentile":6361.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies With Mcc","code_information":[{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7118.84,"maximum":26667.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7118.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12059.97,"10th_percentile":12059.97,"90th_percentile":12059.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies Without Mcc","code_information":[{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4558.63,"maximum":17076.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12947.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14975.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14335.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13530.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9062.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10863.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4558.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17076.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11349.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16560.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14667.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12503.8},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6199.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14257.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4919.39,"10th_percentile":4919.39,"90th_percentile":4919.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5285.91,"10th_percentile":5285.91,"90th_percentile":5285.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6474.79,"10th_percentile":6474.79,"90th_percentile":6474.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4852.69,"10th_percentile":4852.69,"90th_percentile":4852.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6498.67,"10th_percentile":6498.67,"90th_percentile":6498.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":157.58,"10th_percentile":157.58,"90th_percentile":6576.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7258.88,"maximum":27191.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20616.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23846.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22827.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21545.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14430.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7258.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27191.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26369.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23356.21},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19910.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9872.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22702.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8786.66,"10th_percentile":8786.66,"90th_percentile":8786.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4561.37,"maximum":17086.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12954.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14984.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14344.46},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13538.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9067.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10870.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4561.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17086.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11356.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16570.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14676.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12511.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6203.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14265.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":166.88,"10th_percentile":166.88,"90th_percentile":166.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":169.24,"10th_percentile":169.24,"90th_percentile":169.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6374.03,"10th_percentile":6374.03,"90th_percentile":6374.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":113.09,"10th_percentile":113.09,"90th_percentile":113.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis With Mcc","code_information":[{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8165.55,"maximum":30588.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23191.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26825.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25678.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24236.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16232.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19459.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8165.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30588.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20329.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29663.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26273.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22397.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11105.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25538.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12190.72,"10th_percentile":12190.72,"90th_percentile":12190.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12002.11,"10th_percentile":12002.11,"90th_percentile":12002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4905.15,"maximum":18374.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13931.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16114.22},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15425.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14559.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9751.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11689.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18374.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12212.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17819.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15782.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13454.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6671.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15341.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6689.94,"10th_percentile":6689.94,"90th_percentile":6689.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5100.08,"10th_percentile":5100.08,"90th_percentile":5100.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":17769.97,"10th_percentile":17769.97,"90th_percentile":17769.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6050.31,"10th_percentile":6050.31,"90th_percentile":6742.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10241.4,"maximum":38364.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29086.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33644.66},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32206.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30397.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20359.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24405.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10241.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38364.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25498.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37204.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32952.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28090.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13928.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32030.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8836.7,"10th_percentile":8836.7,"90th_percentile":8836.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6184.16,"maximum":23165.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17563.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20315.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19447.75},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18355.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12293.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14737.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6184.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23165.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15396.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22465.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19898.19},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16962.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8410.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19341.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8837.89,"10th_percentile":8837.89,"90th_percentile":8837.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4414.75,"maximum":16537.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12538.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14503.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13883.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13103.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8776.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10520.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4414.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16537.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16037.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14204.91},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12109.15},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13807.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5406.82,"10th_percentile":5406.82,"90th_percentile":5406.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7824.52,"maximum":29310.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22222.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25704.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24606.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23224.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15554.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18646.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29310.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19480.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28424.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25176.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21461.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10641.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24471.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10959.61,"10th_percentile":10959.61,"90th_percentile":10959.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":29613.69,"10th_percentile":29613.69,"90th_percentile":29613.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","code_information":[{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4917.78,"maximum":18422.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13967.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16155.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15465.29},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14596.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9776.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11719.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4917.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18422.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12243.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17865.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15823.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13488.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6688.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15380.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6922.29,"10th_percentile":6922.29,"90th_percentile":6922.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":255.94,"10th_percentile":255.94,"90th_percentile":6938.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6779.88,"10th_percentile":6170.36,"90th_percentile":6944.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4465.27,"10th_percentile":4465.27,"90th_percentile":4465.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6780.59,"10th_percentile":5760.99,"90th_percentile":8331.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":18107.09,"10th_percentile":18107.09,"90th_percentile":18107.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","code_information":[{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8476.93,"maximum":31754.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24075.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27848.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26657.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25160.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16851.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20201.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8476.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31754.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21105.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30794.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27275.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23251.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11528.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26511.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12716.11,"10th_percentile":12716.11,"90th_percentile":12716.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12169.63,"10th_percentile":12169.63,"90th_percentile":12169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5889.93,"10th_percentile":5889.93,"90th_percentile":5889.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5351.08,"maximum":20045.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15197.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17579.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16827.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15882.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10637.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12751.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5351.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20045.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13322.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19439.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17217.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7277.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16735.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6254.89,"10th_percentile":6254.89,"90th_percentile":6254.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1060.26,"10th_percentile":1060.26,"90th_percentile":1060.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4114.9,"maximum":15414.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11686.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13518.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12940.41},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12213.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8180.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4114.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15414.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10244.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14948.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13240.13},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11286.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5596.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12869.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5058.15,"10th_percentile":5058.15,"90th_percentile":5058.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5779.36,"10th_percentile":5779.36,"90th_percentile":5779.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":825.0,"10th_percentile":825.0,"90th_percentile":825.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Mcc","code_information":[{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16151.53,"maximum":60503.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45872.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53060.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50792.8},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47939.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32107.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38490.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16151.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60503.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40212.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58674.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51969.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44301.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21966.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50514.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27362.19,"10th_percentile":27362.19,"90th_percentile":27362.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9278.16,"maximum":34756.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26351.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30480.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29177.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27538.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18444.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22110.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9278.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34756.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23099.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33705.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29853.47},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25448.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12618.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29017.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12099.81,"10th_percentile":12099.81,"90th_percentile":12099.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12808.38,"10th_percentile":12808.38,"90th_percentile":12808.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement Without Cc/Mcc","code_information":[{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6295.1,"maximum":23581.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17878.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20680.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19796.6},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18684.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12514.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6295.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23581.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15672.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.12},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17266.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8561.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19688.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35978.07,"maximum":134774.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102182.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118193.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113142.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106787.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71521.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85738.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35978.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":134774.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89574.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130700.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115763.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98683.74},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48930.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112522.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19063.76,"maximum":71413.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54143.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62627.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59951.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56583.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37897.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45430.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19063.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71413.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69254.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61339.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52289.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25926.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59622.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9868.52,"maximum":36967.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28027.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32419.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31034.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29291.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19617.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23517.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9868.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36967.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24569.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35850.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31752.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27068.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13421.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30864.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26915.73,"maximum":100826.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76444.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88422.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84643.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79889.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53506.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64142.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26915.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":100826.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67012.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97778.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86604.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73826.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36605.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84179.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14556.75,"maximum":54529.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41342.97},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47821.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45777.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28937.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34689.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14556.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54529.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36241.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52881.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46837.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39927.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19797.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45526.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33138.0,"10th_percentile":33138.0,"90th_percentile":33138.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8821.81,"maximum":33046.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25055.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28981.06},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27742.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26184.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17537.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8821.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33046.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21963.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32047.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28385.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24197.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27590.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17784.75,"maximum":66621.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50510.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58425.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55928.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52787.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35354.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42382.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17784.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66621.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44278.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64608.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57224.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48781.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55622.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23353.98,"10th_percentile":23353.98,"90th_percentile":23353.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25283.39,"10th_percentile":25283.39,"90th_percentile":25283.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9489.59,"maximum":35548.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26951.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31174.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28166.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18864.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22614.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9489.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35548.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23626.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34473.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30533.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26028.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12905.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29679.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13739.5,"10th_percentile":13739.5,"90th_percentile":13740.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","code_information":[{"code":"581","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7925.02,"maximum":29687.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22508.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26034.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24922.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23522.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15754.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18885.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7925.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29687.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19730.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28789.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25499.58},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21737.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10778.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24785.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":350.0,"10th_percentile":350.0,"90th_percentile":350.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy With Cc/Mcc","code_information":[{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10580.24,"maximum":39633.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30049.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34757.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33272.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31403.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21032.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25213.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10580.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39633.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26341.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38435.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34043.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29020.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14389.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33090.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13562.69,"10th_percentile":13562.69,"90th_percentile":13562.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy Without Cc/Mcc","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9469.82,"maximum":35474.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26895.47},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31109.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29780.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28107.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18825.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22567.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9469.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35474.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23577.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34401.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25974.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12878.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29617.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","code_information":[{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11756.0,"maximum":44038.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33388.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38620.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36969.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34893.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23370.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11756.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44038.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29268.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37826.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32245.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15988.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36767.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","code_information":[{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10593.97,"maximum":39685.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30088.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34802.89},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33315.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31444.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21059.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25246.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10593.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39685.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26375.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38485.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34087.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29058.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14407.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33132.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13731.71,"10th_percentile":13731.71,"90th_percentile":13731.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":30960.05,"10th_percentile":30960.05,"90th_percentile":30960.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15413.59,"10th_percentile":15413.59,"90th_percentile":15413.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Mcc","code_information":[{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10628.01,"maximum":39812.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30184.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34914.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33422.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31545.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21127.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25327.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10628.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39812.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26460.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38609.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34196.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29151.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14454.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33239.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15925.62,"10th_percentile":15925.62,"90th_percentile":15925.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Cc","code_information":[{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6514.76,"maximum":24404.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18502.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21402.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20487.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19336.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6514.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24404.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16219.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23666.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20961.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17869.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8860.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20375.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers Without Cc/Mcc","code_information":[{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4760.18,"maximum":17831.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13519.48},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15637.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14969.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14128.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9462.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11343.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4760.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17831.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11851.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17292.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15316.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13056.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6473.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14887.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11646.16,"maximum":43626.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33076.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38259.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36624.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34567.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23151.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27753.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43626.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28995.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42307.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37472.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31944.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15838.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36423.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders Without Mcc","code_information":[{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5944.72,"maximum":22269.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16883.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19529.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18694.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17644.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11817.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5944.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22269.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14800.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21595.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19127.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16305.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18592.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8406.11,"10th_percentile":8406.11,"90th_percentile":8406.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Mcc","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9155.15,"maximum":34295.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26001.76},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30076.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28790.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27173.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18199.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21817.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9155.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34295.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33258.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29457.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25111.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12451.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6212.72,"maximum":23272.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17644.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20409.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19537.55},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18440.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12350.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14805.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6212.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23272.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15467.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22569.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19990.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17040.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8449.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19430.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8636.35,"10th_percentile":8636.35,"90th_percentile":8636.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4225.28,"maximum":15827.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12000.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13880.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13287.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12541.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8399.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10069.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4225.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15827.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10519.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15349.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11589.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5746.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13214.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders With Cc/Mcc","code_information":[{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5720.12,"maximum":21427.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16245.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18791.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17988.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11371.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13631.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5720.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21427.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14241.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20779.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15689.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7779.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17889.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3322.46,"maximum":12445.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9436.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10448.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9861.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6604.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7917.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3322.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12445.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8271.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12069.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10690.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9113.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4518.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7805.3,"maximum":29238.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22168.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25641.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24545.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23167.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15516.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7805.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29238.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19432.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28354.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25114.37},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21409.04},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10615.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24411.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9523.59,"10th_percentile":9237.35,"90th_percentile":13222.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11092.05,"10th_percentile":9761.65,"90th_percentile":12396.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":22130.56,"10th_percentile":22130.56,"90th_percentile":22130.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7111.89,"10th_percentile":7111.89,"90th_percentile":7111.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10251.68,"10th_percentile":9258.74,"90th_percentile":11262.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4782.69,"maximum":17916.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13583.43},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15711.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15040.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14195.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9507.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4782.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17916.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11907.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17374.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15388.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13118.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6504.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14958.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6821.61,"10th_percentile":6821.61,"90th_percentile":6821.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13737.83,"10th_percentile":13737.83,"90th_percentile":13737.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6831.8,"10th_percentile":6831.8,"90th_percentile":6831.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4544.09,"10th_percentile":4544.09,"90th_percentile":4544.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6821.61,"10th_percentile":6821.61,"90th_percentile":6821.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.61,"10th_percentile":6779.79,"90th_percentile":6894.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":17607.55,"10th_percentile":17607.55,"90th_percentile":17607.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11971.5,"10th_percentile":11971.5,"90th_percentile":11971.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3363.56,"10th_percentile":3363.56,"90th_percentile":3363.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":4771.57,"10th_percentile":157.58,"90th_percentile":6821.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5614.02,"10th_percentile":5614.02,"90th_percentile":5614.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8084.27,"maximum":30283.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22960.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26558.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25423.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23995.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19265.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30283.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20127.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29368.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26012.01},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22174.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10994.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25283.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13012.02,"10th_percentile":13012.02,"90th_percentile":13012.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5030.36,"maximum":18843.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14286.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16525.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15819.32},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14930.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9999.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11987.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5030.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18843.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12524.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18274.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16185.72},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13797.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6841.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15732.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":5511.38,"10th_percentile":5511.38,"90th_percentile":5511.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7153.86,"10th_percentile":7153.86,"90th_percentile":7153.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6231.38,"10th_percentile":6231.38,"90th_percentile":6231.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7838.4,"10th_percentile":7838.4,"90th_percentile":8527.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders With Mcc","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8309.98,"maximum":31129.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23601.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27299.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26132.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24665.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16519.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19803.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31129.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20689.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30188.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26738.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11301.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25989.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4733.05,"10th_percentile":4733.05,"90th_percentile":4733.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders Without Mcc","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4977.65,"maximum":18646.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14137.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16352.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15653.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14774.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9895.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11862.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4977.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18646.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18082.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16016.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6769.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15567.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures With Cc/Mcc","code_information":[{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12036.62,"maximum":45089.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34185.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39542.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37852.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35726.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23927.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28684.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12036.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45089.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29967.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43726.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38729.11},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33015.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16369.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37644.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16876.18,"10th_percentile":16876.18,"90th_percentile":16876.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures Without Cc/Mcc","code_information":[{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7684.48,"maximum":28786.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21824.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25244.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24165.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22808.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15276.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18312.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7684.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28786.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19132.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27916.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24725.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21077.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10450.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24033.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"616","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19151.62,"maximum":71742.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54392.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62916.18},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60227.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56844.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38071.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45639.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19151.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71742.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47681.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69573.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61622.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52530.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26046.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59897.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29933.62,"10th_percentile":29933.62,"90th_percentile":29933.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17133.52,"10th_percentile":17133.52,"90th_percentile":17133.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"617","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10271.06,"maximum":38475.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29171.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33742.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32300.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20418.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24476.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10271.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38475.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25571.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37312.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33048.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28172.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13968.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32123.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14983.45,"10th_percentile":14983.45,"90th_percentile":14983.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":30944.11,"10th_percentile":30944.11,"90th_percentile":30944.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14890.14,"10th_percentile":14890.14,"90th_percentile":14890.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15052.52,"10th_percentile":15052.52,"90th_percentile":15052.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":29095.69,"10th_percentile":29095.69,"90th_percentile":29095.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14861.7,"10th_percentile":14861.7,"90th_percentile":14959.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7788.82,"maximum":29177.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22121.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25587.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24494.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23118.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15483.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18561.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7788.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29177.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19391.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28295.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21363.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10592.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24359.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Mcc","code_information":[{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15856.63,"maximum":59399.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45034.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52091.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49865.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47064.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31521.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37787.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15856.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59399.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39478.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57603.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51020.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43492.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21565.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49592.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Cc","code_information":[{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8788.3,"maximum":32921.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24959.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28871.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27637.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26084.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17470.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20943.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8788.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32921.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21880.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31925.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28277.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11952.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27485.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8283.62,"maximum":31030.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23526.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27213.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26050.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24586.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19740.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31030.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20623.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30092.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26653.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22721.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11265.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25907.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19545.92,"maximum":73219.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55512.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64211.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58014.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38855.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46579.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19545.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73219.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48663.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71006.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62891.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53612.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26582.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61130.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28254.64,"10th_percentile":28254.64,"90th_percentile":28254.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9851.49,"maximum":36903.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27979.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32363.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30980.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29240.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19584.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23476.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9851.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36903.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24527.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35788.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31698.21},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27021.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13398.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30810.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16647.39,"10th_percentile":16647.39,"90th_percentile":16647.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16486.5,"10th_percentile":16486.5,"90th_percentile":27446.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14760.9,"10th_percentile":14760.9,"90th_percentile":14760.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6875.01,"maximum":25753.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19525.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22585.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21620.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20405.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13666.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16383.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6875.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25753.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17116.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24975.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22121.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18857.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9350.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21501.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","code_information":[{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16585.37,"maximum":62129.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47104.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54485.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52157.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49227.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32970.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39524.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16585.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62129.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41292.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60251.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53365.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45491.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22556.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51871.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","code_information":[{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8234.2,"maximum":30845.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23386.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27050.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25894.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24440.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16368.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8234.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30845.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20500.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29913.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26494.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22585.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11198.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25752.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","code_information":[{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7294.58,"maximum":27325.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20717.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23963.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.74},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21651.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14501.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17383.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7294.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27325.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26499.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23471.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20008.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9920.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22814.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20466.32,"maximum":76667.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58126.9},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67235.2},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64361.84},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60746.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40685.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48772.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20466.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76667.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50955.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74349.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65852.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56136.79},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27834.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64009.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28941.62,"10th_percentile":28941.62,"90th_percentile":28941.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30558.62,"10th_percentile":30558.62,"90th_percentile":30558.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","code_information":[{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11965.23,"maximum":44821.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33982.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39307.73},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37627.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35514.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23785.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28513.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11965.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44821.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43467.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32819.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16272.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37421.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15801.81,"10th_percentile":15801.81,"90th_percentile":15801.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17376.51,"10th_percentile":17376.51,"90th_percentile":17376.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18688.72,"10th_percentile":18688.72,"90th_percentile":18688.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8015.08,"maximum":30024.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22763.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26330.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25205.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23789.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15933.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19100.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8015.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30024.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19955.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29117.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25789.37},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21984.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10900.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25067.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7889.87,"maximum":29555.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22408.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25919.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24811.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7889.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29555.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19643.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28662.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25386.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21641.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10730.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24675.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10958.22,"10th_percentile":10958.22,"90th_percentile":11312.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":22713.91,"10th_percentile":22713.91,"90th_percentile":22713.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10594.19,"10th_percentile":10594.19,"90th_percentile":10594.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6942.82,"10th_percentile":6942.82,"90th_percentile":6942.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10879.28,"10th_percentile":10111.57,"90th_percentile":11311.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21719.0,"10th_percentile":21719.0,"90th_percentile":21936.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9926.52,"10th_percentile":9926.52,"90th_percentile":9926.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4921.63,"maximum":18436.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13978.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16168.34},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15477.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14608.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9783.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11728.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4921.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18436.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12253.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17879.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15835.85},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13499.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6693.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15392.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7759.5,"10th_percentile":7759.5,"90th_percentile":7759.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6633.31,"10th_percentile":6633.31,"90th_percentile":6942.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6612.21,"10th_percentile":6612.21,"90th_percentile":6612.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7131.03,"10th_percentile":7131.03,"90th_percentile":7131.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6633.31,"10th_percentile":6633.31,"90th_percentile":6633.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6930.98,"10th_percentile":6295.03,"90th_percentile":7117.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13815.78,"10th_percentile":10020.5,"90th_percentile":13815.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6612.21,"10th_percentile":6612.21,"90th_percentile":6832.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5306.25,"10th_percentile":5143.53,"90th_percentile":7528.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3411.42,"maximum":12779.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9688.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11207.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10728.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10125.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6781.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8129.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3411.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12779.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10976.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.14},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4639.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5039.73,"10th_percentile":5039.73,"90th_percentile":5039.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":6615.65,"10th_percentile":6615.65,"90th_percentile":6615.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9345.11,"10th_percentile":9345.11,"90th_percentile":9345.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7334.66,"maximum":27475.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20831.35},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24095.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23065.81},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21770.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14580.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27475.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18261.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26645.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23600.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20118.14},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22939.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7330.99,"10th_percentile":7330.99,"90th_percentile":7330.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10691.01,"10th_percentile":10691.01,"90th_percentile":10691.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6652.78,"10th_percentile":6652.78,"90th_percentile":6652.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10243.01,"10th_percentile":10243.01,"90th_percentile":10243.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6652.78,"10th_percentile":6652.78,"90th_percentile":6652.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10233.02,"10th_percentile":8668.09,"90th_percentile":12151.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18179.49,"10th_percentile":18179.49,"90th_percentile":18179.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10163.16,"10th_percentile":302.51,"90th_percentile":10877.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8957.08,"10th_percentile":8957.08,"90th_percentile":8957.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4273.61,"maximum":16009.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12137.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14039.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13439.51},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12684.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8495.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10184.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4273.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16009.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10640.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5812.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13365.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7138.15,"10th_percentile":7138.15,"90th_percentile":7138.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12231.55,"10th_percentile":12231.55,"90th_percentile":12231.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4963.39,"10th_percentile":4963.39,"90th_percentile":4963.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6014.67,"10th_percentile":6014.67,"90th_percentile":6051.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4479.73,"10th_percentile":4479.73,"90th_percentile":4479.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6128.43,"10th_percentile":5633.93,"90th_percentile":7256.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":15590.93,"10th_percentile":15590.93,"90th_percentile":15590.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11770.23,"10th_percentile":8972.25,"90th_percentile":12020.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3241.23,"10th_percentile":3241.23,"90th_percentile":3241.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":4540.23,"10th_percentile":282.58,"90th_percentile":6139.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inborn And Other Disorders Of Metabolism","code_information":[{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7809.69,"maximum":29255.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22180.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25656.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24559.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23180.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18611.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7809.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29255.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19443.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28370.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25128.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10621.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24425.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9623.87,"10th_percentile":9623.87,"90th_percentile":9623.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18694.69,"10th_percentile":18694.69,"90th_percentile":18694.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Mcc","code_information":[{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9039.83,"maximum":33863.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25674.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29697.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28428.15},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26831.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17970.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21542.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9039.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33863.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22506.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32839.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29086.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24795.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12294.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28272.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11157.38,"10th_percentile":11157.38,"90th_percentile":11157.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12849.45,"10th_percentile":12849.45,"90th_percentile":12849.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5628.95,"maximum":21086.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15986.93},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18492.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17701.75},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16707.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11189.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13414.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5628.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21086.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20448.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18111.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15439.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7655.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17604.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16958.63,"10th_percentile":16958.63,"90th_percentile":16958.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8003.46,"10th_percentile":8003.46,"90th_percentile":8164.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8161.96,"10th_percentile":8161.96,"90th_percentile":8161.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4219.24,"maximum":15805.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11983.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13860.9},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13268.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12523.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8387.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10054.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4219.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15805.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10504.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15327.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13575.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11572.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5738.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13195.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5872.55,"10th_percentile":5872.55,"90th_percentile":5872.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis With Mcc","code_information":[{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25818.5,"maximum":96716.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73327.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84817.96},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81193.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76632.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51325.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61527.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25818.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96716.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64280.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93792.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83073.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70817.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35113.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80748.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis Without Mcc","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20351.0,"maximum":76235.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57799.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66856.34},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63999.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60404.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40456.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48497.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20351.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76235.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50667.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73930.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65481.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55820.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27677.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63648.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant","code_information":[{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17735.32,"maximum":66436.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50370.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58263.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55773.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52640.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35256.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42264.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66436.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44155.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64428.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57065.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48645.96},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24120.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55467.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Mcc","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28536.87,"maximum":106899.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81048.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93748.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89741.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84701.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56729.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68005.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28536.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":106899.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71048.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103668.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91820.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78273.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38810.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89249.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Cc","code_information":[{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15372.81,"maximum":57586.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43660.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50502.17},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48343.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45628.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30559.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36634.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15372.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57586.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55846.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49463.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42165.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20907.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48078.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21885.81,"10th_percentile":21885.81,"90th_percentile":21885.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21889.59,"10th_percentile":21889.59,"90th_percentile":21889.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":51609.66,"10th_percentile":51609.66,"90th_percentile":51609.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures Without Cc/Mcc","code_information":[{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11623.65,"maximum":43542.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33012.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38185.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36553.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34500.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23106.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27699.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11623.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43542.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28939.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42226.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37400.32},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31882.35},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15808.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36353.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30996.26,"10th_percentile":30996.26,"90th_percentile":30996.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":39466.8,"10th_percentile":39466.8,"90th_percentile":39466.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Mcc","code_information":[{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17484.35,"maximum":65496.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49657.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57438.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54984.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51895.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34757.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41666.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17484.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65496.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43530.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63516.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56257.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47957.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23778.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54682.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18984.93,"10th_percentile":18984.93,"90th_percentile":18984.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25241.24,"10th_percentile":25241.24,"90th_percentile":25241.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25232.53,"10th_percentile":25232.53,"90th_percentile":25232.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Cc","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10049.74,"maximum":37646.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28542.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33015.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31604.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29829.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19978.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23949.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10049.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37646.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25020.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36508.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32336.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27565.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13667.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31430.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10922.96,"10th_percentile":10922.96,"90th_percentile":10922.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14185.76,"10th_percentile":14185.76,"90th_percentile":14185.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14175.76,"10th_percentile":14175.76,"90th_percentile":14175.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6345.38,"10th_percentile":6345.38,"90th_percentile":6345.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","code_information":[{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8521.96,"maximum":31923.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24203.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27996.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26799.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25294.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16941.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20308.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8521.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31923.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21217.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30958.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27420.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23374.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11589.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26652.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12343.06,"10th_percentile":12343.06,"90th_percentile":12343.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13953.76,"maximum":52271.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39630.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45840.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43881.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41416.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27739.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33252.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13953.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52271.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34740.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50690.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44897.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18977.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43640.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19114.49,"10th_percentile":19114.49,"90th_percentile":19114.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":31951.86,"10th_percentile":31951.86,"90th_percentile":31951.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10400.02,"10th_percentile":10400.02,"90th_percentile":10400.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18415.5,"10th_percentile":18415.5,"90th_percentile":18415.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19951.33,"10th_percentile":18738.36,"90th_percentile":21678.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7258.33,"maximum":27189.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20614.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22825.76},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21543.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14429.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17297.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7258.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27189.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18071.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23354.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9871.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10361.81,"10th_percentile":10361.81,"90th_percentile":10361.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20899.98,"10th_percentile":20899.98,"90th_percentile":20899.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9912.52,"10th_percentile":9912.52,"90th_percentile":9912.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5241.29,"10th_percentile":5241.29,"90th_percentile":5241.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10389.02,"10th_percentile":10378.02,"90th_percentile":12315.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":27564.24,"10th_percentile":27564.24,"90th_percentile":27564.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46706.42,"10th_percentile":46706.42,"90th_percentile":46706.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":18100.81,"10th_percentile":18100.81,"90th_percentile":18100.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":19908.77,"10th_percentile":19908.77,"90th_percentile":19908.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3819.52,"10th_percentile":3819.52,"90th_percentile":4388.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9892.93,"10th_percentile":7761.43,"90th_percentile":10414.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9007.79,"10th_percentile":9007.79,"90th_percentile":9007.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5686.06,"maximum":21300.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16149.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18679.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17881.36},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11303.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13550.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5686.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21300.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14156.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20656.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18295.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15596.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17783.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":14085.4,"10th_percentile":14085.4,"90th_percentile":14085.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16011.88,"10th_percentile":16011.88,"90th_percentile":16011.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3863.1,"10th_percentile":3863.1,"90th_percentile":3863.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7411.79,"10th_percentile":7411.79,"90th_percentile":7411.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5241.29,"10th_percentile":5241.29,"90th_percentile":5241.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":498.37,"10th_percentile":498.37,"90th_percentile":498.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13876.44,"10th_percentile":13876.44,"90th_percentile":13876.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15310.71,"10th_percentile":15310.71,"90th_percentile":15463.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5990.8,"10th_percentile":5990.8,"90th_percentile":5990.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Mcc","code_information":[{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16812.72,"maximum":62980.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47750.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55232.52},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52872.11},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49902.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33422.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40065.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16812.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62980.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41858.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61076.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54096.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46115.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22865.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52582.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24204.76,"10th_percentile":24204.76,"90th_percentile":24204.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Cc","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8348.42,"maximum":31273.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23710.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27425.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26253.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24779.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16596.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19894.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31273.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20785.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30327.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26861.93},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22898.77},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11353.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26109.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11657.89,"10th_percentile":11657.89,"90th_percentile":11657.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11845.2,"10th_percentile":11845.2,"90th_percentile":11845.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures Without Cc/Mcc","code_information":[{"code":"664","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5749.22,"maximum":21536.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16328.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18887.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18079.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17064.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11429.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13700.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5749.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21536.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14313.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20885.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18498.72},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7818.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17980.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7026.48,"10th_percentile":7026.48,"90th_percentile":7026.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Mcc","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17140.58,"maximum":64208.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48681.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.57},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53903.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50875.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34074.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40847.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17140.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64208.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42674.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62267.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55151.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23311.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53607.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Cc","code_information":[{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9606.56,"maximum":35986.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27283.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31559.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30210.41},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28513.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9606.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35986.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23917.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34898.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30910.13},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26349.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13064.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30044.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":30583.04,"10th_percentile":30583.04,"90th_percentile":30583.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12763.5,"10th_percentile":12763.5,"90th_percentile":12763.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy Without Cc/Mcc","code_information":[{"code":"667","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6074.88,"maximum":22756.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17253.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19956.95},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19104.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18031.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12076.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14476.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6074.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22756.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15124.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22068.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19546.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16662.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8261.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18999.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Mcc","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16035.65,"maximum":60069.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45543.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52679.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50428.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47596.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31877.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38214.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16035.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60069.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39924.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58254.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51596.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43983.96},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21808.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50152.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11989.84,"10th_percentile":11989.84,"90th_percentile":11989.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22586.15,"10th_percentile":22586.15,"90th_percentile":22586.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Cc","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8523.06,"maximum":31927.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24206.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27999.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26803.04},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25297.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16943.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20311.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8523.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31927.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21219.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30962.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27423.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23377.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11591.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26656.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12012.27,"10th_percentile":11299.07,"90th_percentile":14449.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12333.37,"10th_percentile":12333.37,"90th_percentile":12333.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures Without Cc/Mcc","code_information":[{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5367.0,"maximum":20104.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15242.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17631.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15929.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12789.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5367.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20104.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19497.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17268.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14721.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7299.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16785.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures With Cc/Mcc","code_information":[{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9857.54,"maximum":36926.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27996.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32383.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30999.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29258.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19596.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23491.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9857.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36926.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24542.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35810.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31717.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27038.09},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30829.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures Without Cc/Mcc","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5928.25,"maximum":22207.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16836.96},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19475.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18642.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17595.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11784.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14127.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5928.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22207.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14759.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21536.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19074.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16260.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8062.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Mcc","code_information":[{"code":"673","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23073.76,"maximum":86434.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65532.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75801.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72561.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68486.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45868.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54986.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23073.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86434.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57446.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83821.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74242.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63288.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31380.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72163.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":33629.62,"10th_percentile":33629.62,"90th_percentile":33629.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32480.58,"10th_percentile":32480.58,"90th_percentile":32480.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":62359.58,"10th_percentile":62359.58,"90th_percentile":62359.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Cc","code_information":[{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12842.8,"maximum":48109.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36475.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42190.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40387.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38119.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25530.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30605.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12842.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48109.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31974.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46655.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41323.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35226.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17466.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40166.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","code_information":[{"code":"675","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9014.02,"maximum":33766.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25600.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29612.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28346.98},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26754.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17919.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9014.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33766.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22442.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32745.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29003.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24724.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12259.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28191.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8133.15,"maximum":30466.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23099.16},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26718.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25576.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24140.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16168.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19381.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8133.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30466.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29545.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26169.27},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22308.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11061.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25436.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11304.95,"10th_percentile":11304.95,"90th_percentile":11304.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":11356.47,"10th_percentile":11356.47,"90th_percentile":11356.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9490.61,"10th_percentile":9490.61,"90th_percentile":11560.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11637.41,"10th_percentile":11193.78,"90th_percentile":11659.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":20003.66,"10th_percentile":20003.66,"90th_percentile":20003.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7929.01,"10th_percentile":7929.01,"90th_percentile":7929.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":9671.91,"10th_percentile":6285.87,"90th_percentile":11657.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4809.6,"maximum":18016.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13659.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15800.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15125.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14275.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9561.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11461.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4809.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18016.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11974.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17472.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15475.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13192.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6541.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6306.14,"10th_percentile":6306.14,"90th_percentile":6306.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":7860.92,"10th_percentile":7860.92,"90th_percentile":7860.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13864.17,"10th_percentile":13864.17,"90th_percentile":13864.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6900.84,"10th_percentile":6900.84,"90th_percentile":6900.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6884.34,"10th_percentile":6884.34,"90th_percentile":6884.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8325.46,"10th_percentile":8325.46,"90th_percentile":8325.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"15","median_amount":6900.84,"10th_percentile":6717.29,"90th_percentile":8158.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13257.5,"10th_percentile":13257.5,"90th_percentile":13257.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7929.01,"10th_percentile":7929.01,"90th_percentile":7929.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"16","median_amount":6187.91,"10th_percentile":692.31,"90th_percentile":6884.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5444.23,"10th_percentile":5444.23,"90th_percentile":5444.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3296.65,"maximum":12349.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9362.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10830.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10367.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9784.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6553.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3296.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12349.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8207.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11975.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10607.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9042.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4483.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10310.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4919.39,"10th_percentile":4919.39,"90th_percentile":4919.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9905.31,"maximum":37105.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28132.31},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32540.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31149.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29400.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19690.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23605.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9905.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37105.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24661.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35983.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31871.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27169.13},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13471.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30979.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Cc","code_information":[{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5754.16,"maximum":21555.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16342.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18903.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18095.51},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17079.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11438.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13712.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5754.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21555.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14326.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20903.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18514.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15783.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7825.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17996.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","code_information":[{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4340.06,"maximum":16257.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12326.31},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14257.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13648.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12881.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8627.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10342.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4340.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16257.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10805.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15766.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13964.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11904.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13573.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6371.98,"maximum":23869.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18097.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20932.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20038.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18912.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12667.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15184.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6371.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23869.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15864.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20502.5},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8665.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19928.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7850.44,"10th_percentile":7850.44,"90th_percentile":9022.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8410.08,"10th_percentile":8410.08,"90th_percentile":9083.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9063.73,"10th_percentile":8381.26,"90th_percentile":10646.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":8844.18,"10th_percentile":280.43,"90th_percentile":9579.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54.55,"10th_percentile":54.55,"90th_percentile":54.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4445.5,"maximum":16652.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12625.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14604.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13980.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13194.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8837.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10593.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4445.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16652.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11067.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16149.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14303.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12193.5},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6045.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13903.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6271.26,"10th_percentile":6034.24,"90th_percentile":6289.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4739.41,"10th_percentile":4739.41,"90th_percentile":4739.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":11253.78,"10th_percentile":11253.78,"90th_percentile":11253.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6242.99,"10th_percentile":6183.34,"90th_percentile":6243.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":6276.76,"10th_percentile":6034.46,"90th_percentile":6913.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11969.0,"10th_percentile":11969.0,"90th_percentile":12089.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"18","median_amount":5093.43,"10th_percentile":280.07,"90th_percentile":6658.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4818.9,"10th_percentile":4818.9,"90th_percentile":4818.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones With Mcc","code_information":[{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7383.54,"maximum":27658.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20970.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24256.12},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23219.52},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21915.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17595.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7383.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27658.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18382.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26822.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23757.32},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20252.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10041.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23092.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6266.18,"10th_percentile":6266.18,"90th_percentile":6266.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4292.84,"maximum":16081.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12192.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14102.65},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13499.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12741.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8533.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10230.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4292.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16081.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15594.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13812.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11774.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5838.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13425.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","code_information":[{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6281.36,"maximum":23530.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17839.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20635.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19753.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18643.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12486.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14968.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6281.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23530.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15638.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22818.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20210.95},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17229.06},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8542.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19645.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","code_information":[{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3783.76,"maximum":14174.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10746.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12430.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11899.03},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11230.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7521.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9016.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3783.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14174.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9420.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13745.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12174.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10378.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5145.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11833.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5463.11,"10th_percentile":5463.11,"90th_percentile":5463.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Stricture","code_information":[{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5918.91,"maximum":22172.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16810.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19444.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18613.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17568.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11766.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14105.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5918.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22172.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14736.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21502.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.73},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16234.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18511.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7765.03,"10th_percentile":7765.03,"90th_percentile":7765.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":157.58,"10th_percentile":157.58,"90th_percentile":157.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9085.4,"maximum":34034.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25803.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29847.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28571.49},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26966.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18061.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21651.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9085.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34034.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22619.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33005.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29233.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24920.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12356.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28414.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12935.4,"10th_percentile":12935.4,"90th_percentile":12935.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":26217.0,"10th_percentile":26217.0,"90th_percentile":26217.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10171.55,"10th_percentile":10171.55,"90th_percentile":12960.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":13018.22,"10th_percentile":11375.74,"90th_percentile":15391.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15362.75,"10th_percentile":15362.75,"90th_percentile":24959.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":13018.23,"10th_percentile":11058.22,"90th_percentile":13054.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5574.04,"maximum":20880.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15830.96},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18311.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17529.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16544.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11080.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13283.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5574.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20880.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13877.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17935.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15288.95},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7580.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17432.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7320.73,"10th_percentile":7320.73,"90th_percentile":7320.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5025.91,"10th_percentile":5025.91,"90th_percentile":5025.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7904.42,"10th_percentile":7904.42,"90th_percentile":7904.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7898.93,"10th_percentile":7898.93,"90th_percentile":7898.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7913.88,"10th_percentile":7898.93,"90th_percentile":7920.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15150.57,"10th_percentile":15150.57,"90th_percentile":15150.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1085.34,"10th_percentile":358.66,"90th_percentile":9442.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6479.1,"10th_percentile":6479.1,"90th_percentile":6479.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","code_information":[{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3788.7,"maximum":14192.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10760.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12446.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11914.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11245.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7531.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9028.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3788.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14192.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9432.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13763.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12190.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.96},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5152.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11849.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10456.73,"10th_percentile":10456.73,"90th_percentile":10456.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures With Cc/Mcc","code_information":[{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10984.97,"maximum":41149.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31198.68},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36087.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34545.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32604.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21837.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26177.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10984.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41149.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27349.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39905.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35345.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30130.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14939.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34355.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15040.53,"10th_percentile":15040.53,"90th_percentile":15040.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures Without Cc/Mcc","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8425.3,"maximum":31561.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23928.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27678.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26495.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25007.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16748.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8425.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31561.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20976.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27109.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11458.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26350.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":45913.84,"10th_percentile":45913.84,"90th_percentile":45913.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":832.8,"10th_percentile":832.8,"90th_percentile":832.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures With Cc/Mcc","code_information":[{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12779.65,"maximum":47872.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36295.78},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41983.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40189.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25404.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30454.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12779.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47872.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31817.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46425.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41119.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35053.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17380.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39968.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures Without Cc/Mcc","code_information":[{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7694.92,"maximum":28825.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21854.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25279.05},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24198.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22839.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15296.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7694.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28825.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19158.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27953.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24759.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21106.28},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10465.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24066.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures With Cc/Mcc","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11443.52,"maximum":42867.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32501.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37593.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35987.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33965.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22748.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27270.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11443.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42867.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28490.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41571.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36820.75},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31388.28},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15563.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35789.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures Without Cc/Mcc","code_information":[{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6039.18,"maximum":22622.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17152.02},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19839.69},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18991.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17925.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12005.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14391.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6039.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22622.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15035.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21939.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19431.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16564.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8213.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18887.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy With Cc/Mcc","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8256.17,"maximum":30927.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23448.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27122.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25963.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24505.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16412.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19675.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8256.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30927.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29992.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26565.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22645.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11228.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25821.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21565.64,"10th_percentile":21565.64,"90th_percentile":21565.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy Without Cc/Mcc","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5806.88,"maximum":21752.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16492.27},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19076.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18261.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17235.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11543.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13838.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5806.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21752.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14457.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21095.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18684.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15927.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7897.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","code_information":[{"code":"715","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12286.49,"maximum":46025.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34895.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40363.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38638.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36467.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24424.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12286.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46025.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30589.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44634.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39533.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33700.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16709.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38426.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","code_information":[{"code":"716","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8078.24,"maximum":30261.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22943.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25404.17},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23977.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16058.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19250.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8078.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30261.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20112.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29346.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25992.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22157.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10986.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25264.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","code_information":[{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10381.99,"maximum":38891.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14119.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14375.96,"10th_percentile":14375.96,"90th_percentile":14375.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7375.85,"maximum":27630.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20948.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24230.87},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23195.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21892.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14662.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17577.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7375.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27630.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18363.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26794.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23732.58},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20231.12},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10031.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23068.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17638.27,"10th_percentile":17638.27,"90th_percentile":17638.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Mcc","code_information":[{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9938.26,"maximum":37228.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28225.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31253.52},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29498.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19756.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23683.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9938.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37228.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24743.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36103.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31977.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13516.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31082.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Cc","code_information":[{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6275.32,"maximum":23507.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17822.69},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20615.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19734.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18626.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12474.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14954.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23507.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15623.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22796.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17212.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8534.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19626.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System Without Cc/Mcc","code_information":[{"code":"724","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3600.88,"maximum":13488.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10226.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11829.48},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11323.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10687.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7158.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8581.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13488.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8965.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13081.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11586.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9876.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4897.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11261.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy With Mcc","code_information":[{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6426.34,"maximum":24073.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18251.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21111.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20209.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19074.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12775.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15314.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6426.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24073.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15999.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23345.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20677.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17626.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8739.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20098.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy Without Mcc","code_information":[{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3964.98,"maximum":14852.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11261.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13025.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.94},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11768.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7882.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9448.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3964.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14852.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9871.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14403.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12757.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10875.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5392.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12400.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5017.73,"10th_percentile":5017.73,"90th_percentile":5017.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System With Mcc","code_information":[{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8143.58,"maximum":30506.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23128.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26753.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25609.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24171.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16188.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19406.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8143.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30506.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20275.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29583.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26202.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22336.92},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11075.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25469.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System Without Mcc","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4454.84,"maximum":16687.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12652.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14634.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14009.42},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13222.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8855.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10616.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4454.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16687.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16183.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14333.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12219.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6058.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13932.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":6620.72,"10th_percentile":6620.72,"90th_percentile":6620.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6397.93,"10th_percentile":6397.93,"90th_percentile":6397.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5814.02,"maximum":21779.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16512.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19100.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18283.75},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17256.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11557.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13855.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5814.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21779.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14475.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21121.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18707.23},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15947.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7907.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18183.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses Without Cc/Mcc","code_information":[{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3690.4,"maximum":13824.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10481.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12123.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11605.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10953.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7336.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8794.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3690.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13824.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9187.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13406.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11874.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10122.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5018.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11541.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","code_information":[{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11697.24,"maximum":43818.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33221.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38427.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36785.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34719.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23253.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27875.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11697.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43818.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29122.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42493.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37637.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32084.19},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15908.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36583.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","code_information":[{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7389.03,"maximum":27679.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20985.76},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24274.17},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23236.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21931.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14688.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17608.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7389.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27679.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18396.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26842.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23774.99},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20267.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10049.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","code_information":[{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19629.94,"maximum":73534.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55751.48},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64487.55},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61731.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58264.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39022.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46779.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19629.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73534.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48872.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71311.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63161.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53842.69},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26696.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61393.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","code_information":[{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11316.12,"maximum":42390.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32139.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37175.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35586.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33587.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22495.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26967.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11316.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42390.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28173.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41108.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36410.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31038.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15389.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35391.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8064.5,"maximum":30209.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22904.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26493.21},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25361.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23936.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16031.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19218.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8064.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30209.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25948.4},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22120.02},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10967.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25222.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","code_information":[{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19675.52,"maximum":73704.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55880.93},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64637.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61874.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58399.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39113.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46888.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19675.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73704.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48986.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71476.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63308.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53967.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26758.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61535.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","code_information":[{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9937.71,"maximum":37226.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28224.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32646.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31251.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29496.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19755.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23682.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9937.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37226.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24741.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36101.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31975.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27258.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13515.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31080.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7831.66,"maximum":29337.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22242.88},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25728.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24628.75},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23245.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15568.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7831.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29337.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19498.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28450.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25199.19},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10651.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24493.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","code_information":[{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10076.1,"maximum":37745.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28617.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33101.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31687.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29907.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20030.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24012.03},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10076.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37745.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25086.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36604.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32420.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27637.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13703.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31513.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","code_information":[{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6813.5,"maximum":25523.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19351.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22383.47},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21426.89},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20223.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13544.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16237.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6813.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25523.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16963.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24751.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21923.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18688.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9266.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21309.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18056.02,"10th_percentile":18056.02,"90th_percentile":18056.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","code_information":[{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11252.96,"maximum":42153.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31959.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36967.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35387.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33400.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22370.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26816.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42153.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28016.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40879.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36207.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30865.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15304.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35194.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","code_information":[{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6246.76,"maximum":23400.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17741.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20521.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19644.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18541.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12418.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14886.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23400.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15552.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22693.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17134.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19536.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures With Cc/Mcc","code_information":[{"code":"746","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9539.56,"maximum":35735.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27093.55},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31339.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29999.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28314.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18963.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22733.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9539.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35735.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23750.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34655.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30694.56},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26165.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12973.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29835.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12977.95,"10th_percentile":12977.95,"90th_percentile":12977.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4721.18,"maximum":17685.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13408.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15509.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14847.02},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14013.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9385.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11250.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4721.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17685.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17151.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15190.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6420.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14765.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Female Reproductive System Reconstructive Procedures","code_information":[{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7618.58,"maximum":28539.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21637.72},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25028.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23958.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22612.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18155.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7618.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28539.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27676.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24513.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20896.9},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10361.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23827.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14100.39,"maximum":52820.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40046.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46322.07},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44342.45},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41851.88},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28030.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33602.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14100.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52820.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35105.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51223.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45369.49},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38675.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19176.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44099.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8104.6,"maximum":30359.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23018.05},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26624.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25487.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19313.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8104.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30359.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20178.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29442.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26077.39},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22229.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11022.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25347.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Mcc","code_information":[{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10113.99,"maximum":37887.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28724.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33226.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.16},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30019.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20105.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24102.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10113.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37887.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25180.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36741.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32542.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27741.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13755.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31631.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Cc","code_information":[{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5973.83,"maximum":22378.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16966.42},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18786.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17731.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11875.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14236.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5973.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22378.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21701.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19221.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16385.53},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8124.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18683.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5274.74,"maximum":19759.27,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14980.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17328.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16587.84},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15656.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10485.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12570.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19759.27},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13132.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19161.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16972.04},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14468.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7173.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16496.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Mcc","code_information":[{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7863.51,"maximum":29456.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22333.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25832.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24728.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23339.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15632.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18739.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7863.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29456.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19577.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28566.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25301.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21568.71},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10694.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9334.41,"10th_percentile":9334.41,"90th_percentile":9334.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Cc","code_information":[{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5376.34,"maximum":20139.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15269.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17662.14},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16907.33},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15957.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12812.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5376.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20139.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13385.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19531.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.93},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14746.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7311.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16814.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9108.01,"10th_percentile":9108.01,"90th_percentile":9108.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3644.26,"maximum":13651.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10350.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11972.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11460.37},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10816.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7244.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8684.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3644.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13651.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9073.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13238.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11725.81},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9995.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4956.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5532.85,"maximum":20726.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15713.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18176.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17399.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16422.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10998.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13185.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5532.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20726.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17802.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15175.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7524.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17304.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","code_information":[{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3132.99,"maximum":11736.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8898.09},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10292.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9852.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9299.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6228.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7466.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3132.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11736.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7800.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11381.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10080.74},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4260.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9798.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5884.87,"maximum":22044.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16713.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19332.74},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18506.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17467.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11698.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14024.03},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5884.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22044.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14651.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21378.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18935.17},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16141.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8003.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7561.0,"10th_percentile":7561.0,"90th_percentile":7561.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":15283.52,"10th_percentile":15283.52,"90th_percentile":15283.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9197.85,"10th_percentile":9197.85,"90th_percentile":9197.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7201.0,"10th_percentile":7201.0,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses With O.R. Procedures","code_information":[{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9279.81,"maximum":34762.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26355.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29182.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27543.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22114.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9279.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34762.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23103.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33711.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29858.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25453.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12620.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29022.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4921.77,"10th_percentile":4921.77,"90th_percentile":4921.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10221.26,"10th_percentile":10221.26,"90th_percentile":10221.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion With D&C, Aspiration Curettage Or Hysterotomy","code_information":[{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5506.49,"maximum":20627.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15639.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18089.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17316.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16344.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13122.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5506.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20627.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13709.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20003.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17717.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15103.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7488.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17221.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11710.36,"10th_percentile":11710.36,"90th_percentile":11710.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5030.02,"10th_percentile":5030.02,"90th_percentile":5030.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3595.39,"maximum":13468.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10211.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11811.44},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11306.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10671.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7147.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8568.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3595.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13468.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8951.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13061.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11568.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9861.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4889.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11244.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1989.76,"10th_percentile":1989.76,"90th_percentile":1989.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":9388.74,"10th_percentile":9388.74,"90th_percentile":9388.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10641.14,"10th_percentile":10641.0,"90th_percentile":10641.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.6,"10th_percentile":88.6,"90th_percentile":88.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4620.14,"maximum":17307.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13121.76},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15177.89},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14529.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13713.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9184.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11010.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4620.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17307.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11502.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16783.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14865.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.5},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6283.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14449.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":6957.75,"10th_percentile":6957.75,"90th_percentile":6957.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13482.58,"maximum":50505.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38292.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44292.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42399.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40018.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26802.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32129.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13482.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50505.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33567.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43381.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36981.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18336.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17524.98,"10th_percentile":17524.98,"90th_percentile":17524.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Cc","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5821.71,"maximum":21808.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16534.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19125.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18307.93},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11573.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13873.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5821.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21808.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14494.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21149.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18731.97},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15968.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7917.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18207.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12545.0,"10th_percentile":12545.0,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5374.15,"10th_percentile":5374.15,"90th_percentile":5374.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":13261.25,"10th_percentile":13261.25,"90th_percentile":13261.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4267.85,"10th_percentile":4267.85,"90th_percentile":4267.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13198.0,"10th_percentile":13198.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5118.24,"10th_percentile":5118.24,"90th_percentile":5118.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5259.92,"maximum":19703.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14938.81},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16541.21},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15612.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10456.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12534.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5259.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19703.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13095.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19108.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16924.33},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14427.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7153.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16450.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":23126.43,"10th_percentile":23126.43,"90th_percentile":23126.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13308.0,"10th_percentile":13308.0,"90th_percentile":13308.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":20594.37,"10th_percentile":20594.37,"90th_percentile":20594.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11466.2,"10th_percentile":11466.2,"90th_percentile":11466.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12585.34,"10th_percentile":10558.4,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4267.85,"10th_percentile":4267.85,"90th_percentile":4267.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9058.5,"maximum":33933.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25727.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29758.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28486.87},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26886.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18007.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21587.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9058.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33933.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32907.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29146.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24846.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12319.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28330.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12545.0,"10th_percentile":12545.0,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13198.0,"10th_percentile":13198.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6133.09,"maximum":22974.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6133.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8341.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11563.07,"10th_percentile":11250.59,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4423.55,"10th_percentile":4423.55,"90th_percentile":4423.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4171.33,"10th_percentile":4171.33,"90th_percentile":4171.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8219.0,"10th_percentile":8219.0,"90th_percentile":8219.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13152.77,"10th_percentile":12259.98,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5265.4,"maximum":19724.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14954.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17297.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16558.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15628.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10467.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12547.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5265.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19724.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13109.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19128.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16942.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14442.4},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7160.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":19083.01,"10th_percentile":15823.32,"90th_percentile":25194.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"15","median_amount":12545.0,"10th_percentile":10561.82,"90th_percentile":13308.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4423.55,"10th_percentile":4423.55,"90th_percentile":5513.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":16509.63,"10th_percentile":16509.63,"90th_percentile":16509.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8498.0,"10th_percentile":8498.0,"90th_percentile":8498.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5364.24,"10th_percentile":5364.24,"90th_percentile":5364.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5513.87,"10th_percentile":4423.55,"90th_percentile":7329.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":13261.25,"10th_percentile":13261.25,"90th_percentile":15833.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11316.63,"10th_percentile":11316.63,"90th_percentile":11316.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"32","median_amount":13067.0,"10th_percentile":11618.18,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5046.72,"10th_percentile":5046.72,"90th_percentile":5046.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9897.08,"maximum":37074.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28108.91},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32513.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31123.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29375.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19674.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23585.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9897.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37074.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24640.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35953.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31844.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27146.54},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13460.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30953.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1005.88,"10th_percentile":1005.88,"90th_percentile":1005.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32639.69,"maximum":122268.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":92700.77},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107226.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102644.25},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96879.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64885.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77782.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32639.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":122268.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81263.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118572.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105021.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89526.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44389.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102081.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":39771.0,"10th_percentile":39771.0,"90th_percentile":39771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5147.55,"10th_percentile":5147.55,"90th_percentile":5147.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":12428.9,"10th_percentile":12428.9,"90th_percentile":12428.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8529.0,"10th_percentile":8529.0,"90th_percentile":8529.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11658.45,"10th_percentile":11658.45,"90th_percentile":16278.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity With Major Problems","code_information":[{"code":"791","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22290.65,"maximum":83501.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":63308.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73228.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70098.93},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66161.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44312.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53120.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22290.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":83501.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55497.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80977.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71722.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61140.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30315.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69714.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4763.91,"10th_percentile":4763.91,"90th_percentile":13496.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4765.7,"10th_percentile":4765.7,"90th_percentile":4765.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4954.0,"10th_percentile":4954.0,"90th_percentile":4954.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":6729.0,"10th_percentile":6729.0,"90th_percentile":6729.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5641.7,"10th_percentile":5641.7,"90th_percentile":5641.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity Without Major Problems","code_information":[{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13450.18,"maximum":50384.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38200.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44186.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42297.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26737.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32052.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13450.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50384.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33486.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48861.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43277.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36892.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18292.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42065.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11061.27,"10th_percentile":11061.27,"90th_percentile":11061.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8650.33,"10th_percentile":8650.33,"90th_percentile":9827.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3578.0,"10th_percentile":3578.0,"90th_percentile":3578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5002.11,"10th_percentile":5002.11,"90th_percentile":5002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":5784.69,"10th_percentile":5784.69,"90th_percentile":5784.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5135.18,"10th_percentile":4608.0,"90th_percentile":13959.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7263.81,"10th_percentile":7263.81,"90th_percentile":7263.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Term Neonate With Major Problems","code_information":[{"code":"793","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22898.03,"maximum":85776.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65033.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75223.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72008.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67964.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45519.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54567.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22898.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85776.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57009.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83183.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73676.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62806.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31141.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71614.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":12235.7,"10th_percentile":12235.7,"90th_percentile":12235.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7431.0,"10th_percentile":7431.0,"90th_percentile":7431.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3846.11,"10th_percentile":3846.11,"90th_percentile":3846.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4035.8,"10th_percentile":4035.8,"90th_percentile":4035.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5002.11,"10th_percentile":5002.11,"90th_percentile":5002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10609.0,"10th_percentile":10609.0,"90th_percentile":10609.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":4114.72,"10th_percentile":3367.97,"90th_percentile":6729.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8014.26,"10th_percentile":8014.26,"90th_percentile":8014.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonate With Other Significant Problems","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8105.14,"maximum":30362.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23019.61},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26626.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25488.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24057.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16112.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19315.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8105.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30362.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20179.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29444.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26079.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22231.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11023.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":1453.91,"10th_percentile":1453.91,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4099.43,"10th_percentile":2489.47,"90th_percentile":5505.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"19","median_amount":2212.2,"10th_percentile":1015.69,"90th_percentile":3641.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2186.72,"10th_percentile":1526.61,"90th_percentile":9601.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":2802.0,"10th_percentile":2802.0,"90th_percentile":2802.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6485.05,"10th_percentile":6485.05,"90th_percentile":6485.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":4356.07,"10th_percentile":4356.07,"90th_percentile":4922.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4846.65,"10th_percentile":4846.65,"90th_percentile":4846.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3577.99,"10th_percentile":3577.99,"90th_percentile":3578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1789.0,"10th_percentile":1789.0,"90th_percentile":1789.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":4964.57,"10th_percentile":4964.57,"90th_percentile":4964.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1526.61,"90th_percentile":2186.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":3470.81,"10th_percentile":3470.81,"90th_percentile":5038.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3632.41,"10th_percentile":3632.41,"90th_percentile":3632.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"34","median_amount":2626.77,"10th_percentile":1240.8,"90th_percentile":4963.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":3994.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":1097.23,"maximum":4110.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":3116.28},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3604.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3450.55},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3256.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2181.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2614.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1097.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":4110.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2731.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3986.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3530.47},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3009.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1492.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3431.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"12","median_amount":2481.66,"10th_percentile":2018.89,"90th_percentile":4074.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"45","median_amount":1966.4,"10th_percentile":1229.0,"90th_percentile":3687.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1521.22,"90th_percentile":3244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":1154.0,"10th_percentile":1154.0,"90th_percentile":1154.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1448.78,"90th_percentile":3244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":2793.38,"10th_percentile":2498.86,"90th_percentile":3814.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":2109.49,"10th_percentile":2109.49,"90th_percentile":2181.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2003.51,"10th_percentile":2003.51,"90th_percentile":2003.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":1453.91,"90th_percentile":3090.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":511.22,"10th_percentile":511.22,"90th_percentile":511.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":1526.61,"10th_percentile":1521.22,"90th_percentile":2239.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":3085.66,"10th_percentile":1668.53,"90th_percentile":3085.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2669.67,"10th_percentile":2402.7,"90th_percentile":2731.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":1453.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":3351.02,"10th_percentile":3351.02,"90th_percentile":3351.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"83","median_amount":2266.0,"10th_percentile":1133.0,"90th_percentile":2928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"27","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Mcc","code_information":[{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6408.77,"maximum":24007.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18201.7},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21053.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20154.09},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19022.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12740.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15272.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6408.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24007.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15955.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23281.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20620.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17578.52},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8715.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20043.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5493.86,"maximum":20580.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15603.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18048.22},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17276.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16306.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13092.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5493.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20580.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13678.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19957.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17677.07},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15069.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7471.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17182.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5256.07,"maximum":19689.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14927.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17267.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16529.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15600.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10448.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12525.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5256.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19689.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13086.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19094.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16911.96},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14416.8},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7201.0,"10th_percentile":7201.0,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Mcc","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24871.18,"maximum":93167.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70637.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81705.88},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78214.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73821.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49442.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59269.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24871.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93167.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61921.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90351.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80025.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68218.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33824.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77785.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Cc","code_information":[{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15428.27,"maximum":57794.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43818.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50684.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48518.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45793.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30670.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36766.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15428.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57794.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38411.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56047.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49642.1},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20982.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48252.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures Without Cc/Mcc","code_information":[{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10483.04,"maximum":39269.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29773.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34438.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32966.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31115.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20839.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24981.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10483.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39269.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26099.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38082.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33730.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28753.76},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14256.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32786.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":73101.34,"10th_percentile":73101.34,"90th_percentile":73101.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21879.33,"maximum":81960.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62140.01},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71877.15},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68805.41},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64940.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43494.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52139.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21879.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81960.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54473.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79482.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70399.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60012.5},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29755.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68428.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","code_information":[{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10208.45,"maximum":38241.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10208.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13883.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7446.69,"maximum":27895.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21149.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24463.6},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22102.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14803.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17745.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7446.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27895.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27052.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23960.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.43},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10127.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23289.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5926.6,"maximum":22201.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16832.28},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19469.85},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18637.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17590.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11781.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14123.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5926.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22201.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14755.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21530.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19069.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16255.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8060.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2783.78,"10th_percentile":2783.78,"90th_percentile":2783.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7131.39,"10th_percentile":7131.39,"90th_percentile":7131.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6728.32,"10th_percentile":6728.32,"90th_percentile":6728.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2838.97,"10th_percentile":2838.97,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4140.71,"maximum":15511.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11760.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13602.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13021.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12290.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8231.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9867.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4140.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15511.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13323.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11357.5},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5631.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2838.97,"10th_percentile":2838.97,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":10229.94,"10th_percentile":10229.94,"90th_percentile":10229.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7561.0,"10th_percentile":7561.0,"90th_percentile":9073.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3507.57,"10th_percentile":2980.92,"90th_percentile":3577.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":11132.6,"10th_percentile":11132.6,"90th_percentile":11132.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":8118.36,"10th_percentile":8118.36,"90th_percentile":8118.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2922.97,"10th_percentile":2628.61,"90th_percentile":2980.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":9986.34,"10th_percentile":9986.34,"90th_percentile":10285.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8407.02,"10th_percentile":7732.58,"90th_percentile":9883.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2783.78,"10th_percentile":2783.78,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":5793.84,"10th_percentile":5793.84,"90th_percentile":5793.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"11","median_amount":7136.0,"10th_percentile":5760.8,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":2838.97,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3702.48,"maximum":13869.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10515.5},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12163.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11643.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10989.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7360.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8823.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3702.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13869.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9218.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13450.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11913.11},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10155.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5035.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11579.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":2783.78,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"13","median_amount":6328.77,"10th_percentile":4788.75,"90th_percentile":9045.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"46","median_amount":6811.0,"10th_percentile":4840.4,"90th_percentile":7602.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":623.43,"10th_percentile":623.43,"90th_percentile":623.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2922.97,"10th_percentile":2628.61,"90th_percentile":3154.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":6535.0,"10th_percentile":5931.0,"90th_percentile":6731.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2980.92,"10th_percentile":2628.61,"90th_percentile":4248.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":6806.61,"10th_percentile":4865.96,"90th_percentile":9091.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2783.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":4908.0,"10th_percentile":3609.95,"90th_percentile":7535.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5075.01,"10th_percentile":5075.01,"90th_percentile":5075.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":13891.08,"10th_percentile":9491.76,"90th_percentile":14597.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":4370.25,"10th_percentile":4370.25,"90th_percentile":4370.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":2628.61,"10th_percentile":2628.61,"90th_percentile":2980.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7489.46,"10th_percentile":6343.96,"90th_percentile":10285.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8660.2,"10th_percentile":7534.02,"90th_percentile":10086.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":7293.8,"10th_percentile":7293.8,"90th_percentile":7765.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"102","median_amount":7130.0,"10th_percentile":5701.27,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12125.04,"maximum":45420.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34436.62},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39832.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38130.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24103.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28894.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12125.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45420.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30187.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44047.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39013.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33257.6},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16490.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37921.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20544.87,"10th_percentile":20544.87,"90th_percentile":20544.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33105.5,"10th_percentile":33105.5,"90th_percentile":33105.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6951.89,"maximum":26041.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19744.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22838.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21862.09},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20634.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13819.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16566.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6951.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26041.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17308.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25254.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22368.45},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9454.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21742.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9591.93,"10th_percentile":9591.93,"90th_percentile":9591.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9601.13,"10th_percentile":9601.13,"90th_percentile":9601.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9596.39,"10th_percentile":9596.39,"90th_percentile":9596.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9631.93,"10th_percentile":9631.93,"90th_percentile":9631.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5747.57,"maximum":21530.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16323.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18881.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18074.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17059.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11425.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13696.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5747.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21530.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14309.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20879.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18493.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15764.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17975.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7711.94,"maximum":28889.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21902.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25334.98},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24252.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22890.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15330.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18378.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7711.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28889.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19200.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24813.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21152.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10488.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13128.43,"10th_percentile":13128.43,"90th_percentile":13128.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8936.15,"10th_percentile":8936.15,"90th_percentile":8936.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5042.44,"maximum":18889.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14321.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16565.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15857.31},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14966.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10023.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12016.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5042.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18889.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12554.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18318.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16224.59},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13830.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6857.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15770.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7728.14,"10th_percentile":7728.14,"90th_percentile":7728.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4171.46,"10th_percentile":4171.46,"90th_percentile":4171.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10075.32,"10th_percentile":10075.32,"90th_percentile":10075.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6069.67,"10th_percentile":6069.67,"90th_percentile":6069.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8248.78,"10th_percentile":8248.78,"90th_percentile":8248.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7153.17,"10th_percentile":5729.17,"90th_percentile":8547.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":18985.77,"10th_percentile":18985.77,"90th_percentile":18985.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13901.64,"10th_percentile":13901.64,"90th_percentile":13901.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7162.27,"10th_percentile":5659.17,"90th_percentile":8542.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8376.44,"maximum":31378.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23790.1},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27517.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26341.93},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24862.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16651.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19961.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8376.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31378.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30429.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26952.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22975.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11391.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26197.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6274.51,"10th_percentile":6274.51,"90th_percentile":6274.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12063.13,"10th_percentile":12063.13,"90th_percentile":12081.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11988.94,"10th_percentile":11988.94,"90th_percentile":12133.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Mcc","code_information":[{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11679.12,"maximum":43750.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33170.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38367.79},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36728.11},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34665.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27832.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11679.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43750.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29077.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42427.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37578.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32034.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15883.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36526.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5568.55,"maximum":20859.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15815.36},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18293.57},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17511.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16528.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11069.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13270.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5568.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20859.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13864.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20229.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17917.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7573.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17415.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","code_information":[{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3470.73,"maximum":13001.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9857.3},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11401.91},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10301.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6899.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8270.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3470.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13001.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8641.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12608.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.44},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4720.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10854.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Mcc","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12529.78,"maximum":46936.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35586.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41162.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39403.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37190.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24908.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29859.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12529.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46936.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31195.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45517.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40315.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34367.74},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17040.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Cc","code_information":[{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6365.93,"maximum":23846.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18080.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20913.13},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20019.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18894.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12654.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15170.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6365.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23846.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15849.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20483.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17461.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8657.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4722.28,"maximum":17689.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13411.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15513.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14850.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14016.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9387.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4722.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17689.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11757.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17155.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15194.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12952.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6422.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14769.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","code_information":[{"code":"820","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32207.5,"maximum":120649.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":91473.29},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105806.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101285.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95596.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64026.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76752.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32207.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":120649.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80187.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117002.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103631.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88341.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43802.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100729.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Cc","code_information":[{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12293.63,"maximum":46052.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34915.44},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40386.58},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38660.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36489.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24438.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12293.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46052.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44660.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39556.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33720.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16719.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38448.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","code_information":[{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6611.96,"maximum":24768.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6611.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8992.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7877.24,"10th_percentile":7877.24,"90th_percentile":7877.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25178.18,"maximum":94317.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71509.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82714.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79179.5},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74732.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50052.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60001.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94317.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62686.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91466.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81013.42},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69060.84},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34242.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78745.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":218452.19,"10th_percentile":218452.19,"90th_percentile":218452.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36253.78,"10th_percentile":36253.78,"90th_percentile":36253.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36241.77,"10th_percentile":36241.77,"90th_percentile":36241.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","code_information":[{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12441.91,"maximum":46607.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35336.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40873.69},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39126.91},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36929.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24733.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29649.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12441.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46607.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45198.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40033.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34126.73},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16920.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38912.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32622.22,"10th_percentile":32622.22,"90th_percentile":32622.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","code_information":[{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7410.45,"maximum":27759.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21046.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24344.53},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23304.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21995.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14731.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17659.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7410.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27759.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18449.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26920.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23843.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20326.01},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10078.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23176.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8395.84,"10th_percentile":8395.84,"90th_percentile":8395.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8015.79,"10th_percentile":8015.79,"90th_percentile":8015.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25688.9,"maximum":96231.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72959.65},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84392.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80785.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76248.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51067.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61218.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25688.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96231.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63957.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93322.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82656.73},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70461.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34936.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80342.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","code_information":[{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12692.33,"maximum":47545.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36047.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41696.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39914.42},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37672.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25231.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30246.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12692.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47545.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31600.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46108.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40838.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34813.61},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17261.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","code_information":[{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9356.69,"maximum":35050.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26574.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30738.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27771.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22297.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9356.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35050.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23295.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30106.15},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25664.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12725.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29263.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","code_information":[{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17353.65,"maximum":65007.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49286.52},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57009.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54573.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51508.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34497.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41354.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17353.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65007.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43205.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63042.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55837.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47599.08},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23600.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54274.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23883.38,"10th_percentile":23883.38,"90th_percentile":23883.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":46451.28,"10th_percentile":46451.28,"90th_percentile":46451.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","code_information":[{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8264.95,"maximum":30960.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23473.49},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27151.71},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25991.35},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24531.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16430.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19695.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8264.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30960.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20577.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26593.35},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22669.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11240.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6603.72,"maximum":24737.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18755.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21694.3},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20767.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19600.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13127.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15737.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6603.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24737.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16441.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23989.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21248.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18113.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8981.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20653.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12265.02,"10th_percentile":12265.02,"90th_percentile":12265.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","code_information":[{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3962.78,"maximum":14844.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11254.8},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.39},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12462.03},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11762.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7877.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9443.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3962.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14844.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9866.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14395.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12750.67},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10869.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5389.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12393.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4325.51,"10th_percentile":4325.51,"90th_percentile":4325.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2871.59,"maximum":10757.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8155.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9433.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9030.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8523.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5708.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6843.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2871.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10757.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7149.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9239.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7876.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3905.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8980.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2122.36,"10th_percentile":2122.36,"90th_percentile":2122.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7930.5,"10th_percentile":7930.5,"90th_percentile":7930.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2228.48,"10th_percentile":2228.48,"90th_percentile":2228.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2975.42,"10th_percentile":2975.42,"90th_percentile":2975.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":2990.03,"10th_percentile":2990.03,"90th_percentile":2990.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30148.67,"maximum":112937.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85625.97},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99043.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94810.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89485.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59933.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71846.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30148.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112937.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75061.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109523.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97006.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82694.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41002.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94290.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Cc","code_information":[{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11454.51,"maximum":42908.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32532.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37629.92},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36021.77},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33998.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22770.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27296.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11454.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42908.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28518.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41611.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36856.09},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31418.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15578.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35824.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia Without Cc/Mcc","code_information":[{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6697.08,"maximum":25087.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19020.54},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22001.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21060.77},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19877.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13313.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15959.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25087.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16673.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24329.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21548.57},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18369.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9108.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20945.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","code_information":[{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26383.59,"maximum":98833.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74932.67},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86674.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82970.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78310.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52448.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62873.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26383.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":98833.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65687.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95845.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84891.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72367.17},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35881.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82515.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","code_information":[{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11463.29,"maximum":42941.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32557.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37658.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36049.4},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34024.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22788.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27317.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11463.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42941.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28540.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41643.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36884.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31442.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15590.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35851.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7929.41,"maximum":29703.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22520.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26049.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24936.15},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23535.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15763.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18896.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7929.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29703.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19741.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25513.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21749.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10784.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24799.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Mcc","code_information":[{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17764.98,"maximum":66547.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50454.74},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58360.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55866.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52728.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35315.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42335.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17764.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66547.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44229.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64536.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57160.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48727.3},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24160.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55560.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24007.69,"10th_percentile":24007.69,"90th_percentile":24007.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24581.69,"10th_percentile":24581.69,"90th_percentile":24581.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8959.09,"maximum":33560.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25444.95},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29432.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28174.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26591.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17809.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8959.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33560.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22305.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32546.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28826.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24573.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12184.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28019.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12074.85,"10th_percentile":12074.85,"90th_percentile":12074.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.58,"10th_percentile":282.58,"90th_percentile":282.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","code_information":[{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5548.78,"maximum":20785.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15759.21},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18228.63},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17449.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16469.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11030.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13223.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5548.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20785.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13814.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20157.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17853.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15219.66},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7546.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17353.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8172.54,"10th_percentile":8172.54,"90th_percentile":8172.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10954.77,"maximum":41036.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31112.9},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34450.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32515.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21777.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26105.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10954.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41036.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27274.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39796.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35248.12},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30047.67},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14898.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34261.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13451.2,"10th_percentile":13451.2,"90th_percentile":13451.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6685.55,"maximum":25044.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18987.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21963.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21024.5},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19843.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13290.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6685.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25044.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16645.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24287.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21511.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9092.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20909.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18003.3,"10th_percentile":18003.3,"90th_percentile":18003.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9315.79,"10th_percentile":9315.79,"90th_percentile":9315.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","code_information":[{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4676.7,"maximum":17519.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13282.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15363.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14707.13},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13881.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9296.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11144.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4676.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17519.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11643.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16989.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15047.77},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12827.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6360.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14626.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","code_information":[{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14237.13,"maximum":53332.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40435.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46771.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.48},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42257.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28302.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33928.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14237.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53332.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35446.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51720.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45809.48},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39050.83},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19362.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44527.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7184.19,"maximum":26912.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20404.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23601.24},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22592.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21323.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14281.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17120.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7184.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26912.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17886.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26098.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19705.42},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9770.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22468.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4664.62,"maximum":17473.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13248.09},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15324.03},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14669.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13845.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11116.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4664.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17473.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11613.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16945.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12794.51},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6343.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14588.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Radiotherapy","code_information":[{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14879.66,"maximum":55739.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42260.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48882.09},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46793.07},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44164.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29579.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35459.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14879.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55739.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37045.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54054.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47876.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40813.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20236.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46536.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Other Procedures","code_information":[{"code":"850","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47555.05,"maximum":178142.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135062.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156226.04},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149549.57},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141149.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94535.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113326.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47555.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":178142.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118397.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172757.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153013.37},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130438.05},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64674.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148729.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27121.12,"maximum":101596.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77027.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89097.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85289.62},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80499.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53914.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64631.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27121.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":101596.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67523.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98525.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87265.06},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74390.13},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36884.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84822.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19067.23,"10th_percentile":19067.23,"90th_percentile":19067.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38771.03,"10th_percentile":38771.03,"90th_percentile":38771.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":41826.88,"10th_percentile":41826.88,"90th_percentile":53341.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38776.03,"10th_percentile":38776.03,"90th_percentile":38776.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":56626.22,"10th_percentile":56626.22,"90th_percentile":56626.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":109667.68,"10th_percentile":109667.68,"90th_percentile":109667.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17873.56,"10th_percentile":17873.56,"90th_percentile":17873.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":38759.23,"10th_percentile":35257.15,"90th_percentile":44211.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":42097.33,"10th_percentile":42097.33,"90th_percentile":42097.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":66169.88,"10th_percentile":66169.88,"90th_percentile":66169.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":75334.58,"10th_percentile":75334.58,"90th_percentile":108434.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":36308.53,"10th_percentile":14121.6,"90th_percentile":37945.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10972.89,"maximum":41104.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31164.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36047.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34507.19},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32569.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21813.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26149.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10972.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41104.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27319.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39862.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35306.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30097.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14923.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34318.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15543.99,"10th_percentile":15543.99,"90th_percentile":16946.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28770.19,"10th_percentile":28770.19,"90th_percentile":30736.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15509.11,"10th_percentile":15509.11,"90th_percentile":15509.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5714.09,"10th_percentile":5714.09,"90th_percentile":5714.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15185.47,"10th_percentile":8285.35,"90th_percentile":15891.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21046.02,"10th_percentile":21046.02,"90th_percentile":30097.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19067.23,"10th_percentile":19067.23,"90th_percentile":19067.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14339.94,"10th_percentile":14339.94,"90th_percentile":14339.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8222.12,"maximum":30800.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23351.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27010.99},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25856.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24404.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16344.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19593.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8222.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30800.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20470.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29869.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26455.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.32},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11182.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25714.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","code_information":[{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24979.92,"maximum":93575.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70946.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82063.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78556.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74143.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49658.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59528.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24979.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93575.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62192.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90746.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80375.53},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68517.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33972.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78125.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":36946.5,"10th_percentile":36946.5,"90th_percentile":36946.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33669.91,"10th_percentile":33669.91,"90th_percentile":33669.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11760.4,"maximum":44054.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33400.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38634.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36983.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34906.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23378.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28025.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11760.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44054.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42722.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37840.31},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32257.41},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15994.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36781.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18718.5,"10th_percentile":18718.5,"90th_percentile":18718.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19923.19,"10th_percentile":19923.19,"90th_percentile":19923.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32820.77,"10th_percentile":32820.77,"90th_percentile":32820.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16771.66,"10th_percentile":16771.66,"90th_percentile":16771.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7649.33,"maximum":28654.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21725.06},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25129.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22704.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15206.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18228.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7649.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28654.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27788.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24612.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20981.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10403.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10015.15,"maximum":37516.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10015.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13620.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14252.95,"10th_percentile":14252.95,"90th_percentile":14252.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16695.25,"10th_percentile":16695.25,"90th_percentile":16695.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8328.17,"10th_percentile":8328.17,"90th_percentile":8328.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17091.58,"10th_percentile":17091.58,"90th_percentile":17091.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5480.13,"maximum":20528.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15564.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18003.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17233.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16265.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10894.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13059.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5480.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20528.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13643.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17632.89},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15031.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7452.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17139.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2852.72,"10th_percentile":2852.72,"90th_percentile":2852.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":15595.44,"10th_percentile":15595.44,"90th_percentile":15595.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10915.9,"10th_percentile":10915.9,"90th_percentile":10915.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7776.32,"10th_percentile":7776.32,"90th_percentile":7776.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4874.95,"maximum":18261.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13845.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16015.0},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.58},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14469.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9691.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11617.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4874.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18261.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12137.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15685.66},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13371.43},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6629.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15246.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":15056.77,"10th_percentile":15056.77,"90th_percentile":15056.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6976.82,"10th_percentile":6976.82,"90th_percentile":6976.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8074.49,"10th_percentile":8074.49,"90th_percentile":8074.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10414.0,"10th_percentile":10414.0,"90th_percentile":10414.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness With Mcc","code_information":[{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8228.16,"maximum":30822.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23368.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27030.83},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25875.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24422.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16356.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19608.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8228.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30822.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29891.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26474.96},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22568.89},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11190.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25733.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10852.33,"10th_percentile":10852.33,"90th_percentile":10852.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9999.74,"10th_percentile":9999.74,"90th_percentile":9999.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10036.56,"10th_percentile":10036.56,"90th_percentile":10036.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4775.55,"maximum":17889.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13563.15},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15688.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15017.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14174.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9493.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11380.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4775.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17889.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11889.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17348.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15365.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13098.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6494.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14935.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.52,"10th_percentile":5519.79,"90th_percentile":6863.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6884.2,"10th_percentile":6884.2,"90th_percentile":6884.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Mcc","code_information":[{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11495.14,"maximum":43061.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32647.64},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37763.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36149.56},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34119.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22851.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27393.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11495.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43061.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28619.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41759.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36986.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31529.87},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15633.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35951.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":33444.65,"10th_percentile":33444.65,"90th_percentile":33444.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5662.46,"maximum":21211.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16082.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18602.08},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17807.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16806.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11256.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13494.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5662.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21211.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14097.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20570.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18219.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15531.46},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7700.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8625.14,"10th_percentile":8625.14,"90th_percentile":8625.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6172.81,"10th_percentile":6172.81,"90th_percentile":6172.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","code_information":[{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4007.26,"maximum":15011.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11381.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13164.52},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12601.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11894.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7966.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4007.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15011.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9976.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14557.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12893.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.47},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5449.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12532.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9325.96,"10th_percentile":9325.96,"90th_percentile":9325.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis With Mv >96 Hours","code_information":[{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37957.27,"maximum":142188.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":107803.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124695.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119366.79},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112662.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75456.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90454.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37957.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":142188.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94502.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137890.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122131.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104112.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51621.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":164923.34,"10th_percentile":164923.34,"90th_percentile":164923.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54566.72,"10th_percentile":54566.72,"90th_percentile":54566.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":95113.51,"10th_percentile":95113.51,"90th_percentile":95113.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":64303.13,"10th_percentile":64303.13,"90th_percentile":64303.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10667.55,"maximum":39960.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30297.17},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35044.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33546.98},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31662.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21206.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25421.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10667.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39960.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26559.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38752.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34323.98},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29259.88},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14507.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33363.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8917.52,"10th_percentile":8917.52,"90th_percentile":8917.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"15","median_amount":15231.46,"10th_percentile":13553.58,"90th_percentile":16429.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":38270.4,"10th_percentile":33677.56,"90th_percentile":74065.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":27234.02,"10th_percentile":25620.94,"90th_percentile":30602.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":18350.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":51295.53,"10th_percentile":51295.53,"90th_percentile":51295.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17668.91,"10th_percentile":17668.91,"90th_percentile":17668.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"20","median_amount":13785.8,"10th_percentile":6779.79,"90th_percentile":16699.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16515.97,"10th_percentile":16515.97,"90th_percentile":16515.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15169.32,"10th_percentile":15169.32,"90th_percentile":15169.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":3250.0,"10th_percentile":3250.0,"90th_percentile":3250.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":9363.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"84","median_amount":15201.56,"10th_percentile":13579.06,"90th_percentile":15513.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":40368.16,"10th_percentile":40368.16,"90th_percentile":40368.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26827.03,"10th_percentile":26827.03,"90th_percentile":26827.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":37249.31,"10th_percentile":37249.31,"90th_percentile":37249.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"19","median_amount":26899.33,"10th_percentile":12351.66,"90th_percentile":29555.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17477.09,"10th_percentile":17477.09,"90th_percentile":17477.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"56","median_amount":13765.26,"10th_percentile":6154.63,"90th_percentile":16587.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13922.18,"10th_percentile":13922.17,"90th_percentile":16855.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5619.62,"maximum":21051.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15960.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18461.36},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17672.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16679.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11171.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13391.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5619.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21051.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13991.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20414.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18081.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15413.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7642.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17575.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9543.75,"10th_percentile":9543.75,"90th_percentile":9543.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":13179.67,"10th_percentile":13179.67,"90th_percentile":13179.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16080.51,"10th_percentile":15276.48,"90th_percentile":16083.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":9363.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":15536.78,"10th_percentile":15536.78,"90th_percentile":15536.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":11768.69,"10th_percentile":11768.69,"90th_percentile":11768.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10885.3,"10th_percentile":10885.3,"90th_percentile":10885.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6215.97,"10th_percentile":6215.97,"90th_percentile":7922.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":8006.87,"10th_percentile":7989.37,"90th_percentile":9531.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"12","median_amount":13267.49,"10th_percentile":10671.43,"90th_percentile":15529.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1663.0,"10th_percentile":1663.0,"90th_percentile":1663.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":7413.92,"10th_percentile":5376.1,"90th_percentile":9055.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Principal Diagnosis Of Mental Illness","code_information":[{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21224.72,"maximum":79508.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60280.85},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69726.66},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66746.82},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62997.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42193.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50579.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21224.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79508.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52843.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77104.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68292.78},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58216.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28865.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66381.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4968.27,"10th_percentile":4968.27,"90th_percentile":4968.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28791.45,"10th_percentile":28791.45,"90th_percentile":28791.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9101.19,"10th_percentile":9101.19,"90th_percentile":9101.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Adjustment Reaction And Psychosocial Dysfunction","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5273.09,"maximum":19753.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14976.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17322.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16582.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15651.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10482.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5273.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19753.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19155.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.73},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14463.49},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7171.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16491.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6912.88,"10th_percentile":4032.25,"90th_percentile":6912.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":9525.0,"10th_percentile":9525.0,"90th_percentile":14951.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6810.25,"10th_percentile":6810.25,"90th_percentile":6810.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5996.5,"10th_percentile":5996.5,"90th_percentile":5996.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":13377.47,"10th_percentile":13377.47,"90th_percentile":13377.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9651.29,"10th_percentile":9651.29,"90th_percentile":9651.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7402.33,"10th_percentile":7402.33,"90th_percentile":7402.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8277.0,"10th_percentile":8277.0,"90th_percentile":8277.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7575.67,"10th_percentile":7575.67,"90th_percentile":9115.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7226.76,"10th_percentile":7226.76,"90th_percentile":7226.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Depressive Neuroses","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5167.1,"maximum":19356.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14675.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16974.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16249.34},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15336.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10271.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12313.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5167.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19356.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12864.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18770.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16625.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14172.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7027.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16160.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5452.1,"10th_percentile":5452.1,"90th_percentile":5452.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4414.6,"10th_percentile":4414.6,"90th_percentile":4414.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6044.7,"10th_percentile":6044.7,"90th_percentile":10846.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8450.81,"10th_percentile":8450.81,"90th_percentile":8450.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7101.51,"10th_percentile":7101.51,"90th_percentile":7101.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4312.48,"10th_percentile":4312.48,"90th_percentile":4312.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":9792.36,"10th_percentile":9792.36,"90th_percentile":9792.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6430.0,"10th_percentile":6044.7,"90th_percentile":9418.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neuroses Except Depressive","code_information":[{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5896.95,"maximum":22090.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16748.06},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19372.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18544.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17502.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14052.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5896.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22090.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21422.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18974.05},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16174.65},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8019.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18442.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3873.25,"10th_percentile":3873.25,"90th_percentile":3873.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":1905.0,"10th_percentile":1905.0,"90th_percentile":1966.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6096.51,"10th_percentile":6096.51,"90th_percentile":6096.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7274.9,"10th_percentile":7274.9,"90th_percentile":7274.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7650.25,"10th_percentile":7650.25,"90th_percentile":7650.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6203.5,"10th_percentile":6203.5,"90th_percentile":6203.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":142.88,"10th_percentile":142.88,"90th_percentile":142.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Personality And Impulse Control","code_information":[{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10798.25,"maximum":40450.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30668.38},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35474.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33958.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32050.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21466.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25732.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10798.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40450.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26884.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39227.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34744.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29618.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14685.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33771.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9358.92,"10th_percentile":9358.92,"90th_percentile":9358.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12758.71,"10th_percentile":12758.71,"90th_percentile":12758.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":1869.0,"10th_percentile":1869.0,"90th_percentile":1869.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6069.44,"10th_percentile":6069.44,"90th_percentile":6069.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14391.07,"10th_percentile":14391.07,"90th_percentile":14391.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6069.44,"10th_percentile":6034.86,"90th_percentile":6069.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4430.75,"10th_percentile":4430.75,"90th_percentile":4430.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8835.53,"maximum":33098.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25094.01},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29026.16},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27785.7},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26225.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17564.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21055.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8835.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33098.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21997.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28429.26},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24234.86},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12016.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27633.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":13135.36,"10th_percentile":13135.36,"90th_percentile":13135.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27793.4,"10th_percentile":27793.4,"90th_percentile":27793.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6334.05,"10th_percentile":6334.05,"90th_percentile":6334.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11191.16,"10th_percentile":11191.16,"90th_percentile":11191.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12583.51,"10th_percentile":11343.23,"90th_percentile":13351.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13199.35,"10th_percentile":13199.35,"90th_percentile":13199.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11199.35,"10th_percentile":11199.35,"90th_percentile":11199.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7670.75,"maximum":28734.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21785.89},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25199.67},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24122.74},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22767.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15248.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18279.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7670.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28734.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27866.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24681.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21040.0},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23990.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":5544.88,"10th_percentile":4161.5,"90th_percentile":8464.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":10487.51,"10th_percentile":9274.58,"90th_percentile":10950.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"11","median_amount":6063.0,"10th_percentile":1519.0,"90th_percentile":20167.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"27","median_amount":5715.0,"10th_percentile":1905.0,"90th_percentile":11430.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":5892.0,"10th_percentile":5892.0,"90th_percentile":5892.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6932.54,"10th_percentile":6099.5,"90th_percentile":6932.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":7039.14,"10th_percentile":4968.27,"90th_percentile":7760.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"1 through 10","median_amount":10046.76,"10th_percentile":10046.76,"90th_percentile":10046.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5216.68,"10th_percentile":4968.27,"90th_percentile":5822.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":6853.34,"10th_percentile":6853.34,"90th_percentile":14546.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5492.87,"10th_percentile":5492.87,"90th_percentile":6932.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":9451.58,"10th_percentile":8844.7,"90th_percentile":10164.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5805.25,"10th_percentile":5805.25,"90th_percentile":5805.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":8956.33,"10th_percentile":6331.04,"90th_percentile":10907.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5544.88,"10th_percentile":5492.87,"90th_percentile":7760.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9317.7,"10th_percentile":9317.7,"90th_percentile":9317.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4655.77,"10th_percentile":4655.77,"90th_percentile":4655.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":9866.67,"10th_percentile":9866.67,"90th_percentile":9866.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5492.87,"10th_percentile":4213.5,"90th_percentile":10869.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":10503.68,"10th_percentile":9274.58,"90th_percentile":10948.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":6160.48,"10th_percentile":4853.12,"90th_percentile":11467.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5591.29,"10th_percentile":5591.29,"90th_percentile":5591.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3051.6,"10th_percentile":3051.6,"90th_percentile":3851.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":17673.67,"10th_percentile":17673.67,"90th_percentile":17673.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"13","median_amount":3602.4,"10th_percentile":1355.75,"90th_percentile":7154.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":6004.0,"10th_percentile":3503.0,"90th_percentile":7320.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":5492.87,"10th_percentile":4870.1,"90th_percentile":8441.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"51","median_amount":7039.14,"10th_percentile":4968.27,"90th_percentile":9139.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10869.8,"10th_percentile":4211.75,"90th_percentile":11139.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9557.61,"10th_percentile":6271.06,"90th_percentile":12994.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Behavioral And Developmental Disorders","code_information":[{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11396.84,"maximum":42692.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32368.45},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37440.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35840.43},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33827.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22656.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27159.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11396.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42692.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28374.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41402.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36670.55},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31260.24},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15499.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35644.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Mental Disorder Diagnoses","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5881.02,"maximum":22030.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16702.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19320.11},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18494.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17455.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11691.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5881.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22030.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14642.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21364.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18922.8},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16130.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7998.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18393.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":125.0,"10th_percentile":125.0,"90th_percentile":125.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3387.8,"maximum":12690.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9621.79},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11129.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10653.86},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10055.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6734.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8073.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3387.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12690.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8434.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12307.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10900.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9292.36},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4607.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10595.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5633.75,"10th_percentile":5633.75,"90th_percentile":5633.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":11047.4,"10th_percentile":11047.4,"90th_percentile":11047.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":20169.63,"10th_percentile":20169.63,"90th_percentile":20169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5022.25,"10th_percentile":5022.25,"90th_percentile":5022.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9307.83,"10th_percentile":9307.83,"90th_percentile":9307.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":1126.6,"10th_percentile":1126.6,"90th_percentile":1126.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5561.81,"10th_percentile":5561.81,"90th_percentile":5561.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3547.36,"10th_percentile":3547.36,"90th_percentile":3547.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7774.0,"maximum":29121.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22079.11},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25538.84},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24447.41},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23074.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18525.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7774.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29121.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19354.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28241.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25013.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21323.18},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24313.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9583.5,"maximum":35899.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27218.32},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31483.35},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30137.88},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28445.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19051.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22838.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35899.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23860.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34814.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30835.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26286.44},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13033.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29972.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13143.72,"10th_percentile":13143.72,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8555.8,"10th_percentile":8555.8,"90th_percentile":8555.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13800.91,"10th_percentile":13800.91,"90th_percentile":13800.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13800.91,"10th_percentile":13800.91,"90th_percentile":13800.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7302.07,"10th_percentile":7302.07,"90th_percentile":7302.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11430.79,"10th_percentile":11430.79,"90th_percentile":11430.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":2093.74,"10th_percentile":2093.74,"90th_percentile":2093.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7303.37,"10th_percentile":7303.37,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7610.41,"10th_percentile":7610.41,"90th_percentile":7610.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4848.04,"maximum":18160.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13769.03},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15926.59},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15245.96},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14389.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9637.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11553.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4848.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18160.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12070.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17611.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15599.08},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13297.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6593.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15162.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":7191.81,"10th_percentile":5412.12,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6212.36,"10th_percentile":5412.12,"90th_percentile":7345.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":2522.94,"10th_percentile":1869.0,"90th_percentile":7476.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7303.37,"10th_percentile":3473.47,"90th_percentile":12450.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7668.54,"10th_percentile":7191.81,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7303.37,"10th_percentile":7303.37,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":7668.54,"10th_percentile":6063.5,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":13704.51,"10th_percentile":13704.51,"90th_percentile":16087.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5573.25,"10th_percentile":5412.12,"90th_percentile":5611.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6023.96,"10th_percentile":6023.96,"90th_percentile":6070.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7191.81,"10th_percentile":5783.08,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"1 through 10","median_amount":11644.79,"10th_percentile":11644.79,"90th_percentile":11644.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":7551.4,"10th_percentile":6610.81,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6790.56,"10th_percentile":6790.56,"90th_percentile":7085.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8084.5,"10th_percentile":8084.5,"90th_percentile":11324.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4057.43,"10th_percentile":3006.73,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":5083.26,"10th_percentile":5083.26,"90th_percentile":5083.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"17","median_amount":7303.37,"10th_percentile":1150.0,"90th_percentile":13157.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":4503.0,"10th_percentile":4503.0,"90th_percentile":10984.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":7303.37,"10th_percentile":2434.25,"90th_percentile":8566.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6971.9,"10th_percentile":5412.12,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4971.9,"10th_percentile":258.56,"90th_percentile":6971.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5377.96,"10th_percentile":5082.61,"90th_percentile":6969.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Mcc","code_information":[{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23046.31,"maximum":86331.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65454.37},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75710.86},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72475.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68404.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45814.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54920.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23046.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86331.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57378.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83722.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74153.92},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63213.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31342.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72078.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Cc","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10513.78,"maximum":39384.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29860.46},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34539.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33063.42},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31206.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20900.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25055.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10513.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39384.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38194.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33829.22},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28838.11},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14298.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32882.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries Without Cc/Mcc","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6423.04,"maximum":24060.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18242.25},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21100.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20198.99},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19064.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12768.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15306.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6423.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24060.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15991.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23333.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20666.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17617.68},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8735.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries With Cc/Mcc","code_information":[{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20171.42,"maximum":75562.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57289.34},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66266.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63434.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59871.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40099.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48069.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20171.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75562.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50220.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73278.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64903.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55327.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63086.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries Without Cc/Mcc","code_information":[{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8146.33,"maximum":30516.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23136.59},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26762.02},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25618.32},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24179.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19413.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8146.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30516.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20281.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29593.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26211.68},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22344.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25477.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Procedures For Injuries","code_information":[{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10787.27,"maximum":40409.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30637.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35437.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33923.46},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32018.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25706.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10787.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40409.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26857.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34709.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29588.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14670.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33737.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Mcc","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21084.14,"maximum":78981.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59881.56},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69264.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66304.71},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62580.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41913.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50244.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21084.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78981.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52493.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76594.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67840.43},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57831.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28674.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65941.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28892.94,"10th_percentile":28892.94,"90th_percentile":28892.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Cc","code_information":[{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10956.97,"maximum":41044.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31119.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35995.4},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34457.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32521.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21781.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26111.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10956.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41044.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27279.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39804.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35255.18},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30053.7},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14901.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34268.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28246.0,"10th_percentile":28246.0,"90th_percentile":28246.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15636.02,"10th_percentile":15636.02,"90th_percentile":15636.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14769.51,"10th_percentile":14769.51,"90th_percentile":18562.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries Without Cc/Mcc","code_information":[{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7208.9,"maximum":27004.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20474.18},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23682.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22670.33},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21397.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14330.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17179.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7208.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27004.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17948.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26188.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23195.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.2},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9804.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22546.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11901.46,"10th_percentile":11901.46,"90th_percentile":11901.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury With Mcc","code_information":[{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8976.67,"maximum":33626.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25494.86},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29489.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28229.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26643.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17844.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21392.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8976.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33626.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22349.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32610.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24621.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12208.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28074.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury Without Mcc","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4862.86,"maximum":18216.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13811.14},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15975.31},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15292.59},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14433.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9667.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11588.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4862.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18216.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12107.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17665.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15646.79},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13338.29},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6613.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15208.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7121.71,"10th_percentile":7121.71,"90th_percentile":7121.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5661.46,"10th_percentile":5661.46,"90th_percentile":5661.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions With Mcc","code_information":[{"code":"915","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9234.78,"maximum":34593.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26227.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30337.75},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.23},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27410.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18358.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22007.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9234.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34593.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22991.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33547.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29713.87},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25329.94},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12559.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28882.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3659.09,"maximum":13707.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10392.28},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12020.72},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11507.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10860.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7274.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8719.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3659.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13707.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9110.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13292.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11773.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10036.48},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4976.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11443.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6209.84,"10th_percentile":6209.84,"90th_percentile":6209.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9079.98,"10th_percentile":9079.98,"90th_percentile":9079.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3998.85,"10th_percentile":3998.85,"90th_percentile":3998.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs With Mcc","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8613.12,"maximum":32264.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24462.33},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28295.5},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27086.27},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25564.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17122.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20525.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8613.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32264.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31289.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27713.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23624.81},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11713.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11056.66,"10th_percentile":11056.66,"90th_percentile":11831.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":18810.53,"10th_percentile":18810.53,"90th_percentile":18810.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14122.09,"10th_percentile":14122.09,"90th_percentile":14122.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14699.0,"10th_percentile":14699.0,"90th_percentile":14699.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14293.37,"10th_percentile":14293.37,"90th_percentile":14293.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12948.94,"10th_percentile":12948.94,"90th_percentile":12948.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":12911.0,"10th_percentile":12911.0,"90th_percentile":12911.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17712.65,"10th_percentile":13509.86,"90th_percentile":24323.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6597.75,"10th_percentile":6597.75,"90th_percentile":6597.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10910.65,"10th_percentile":10910.65,"90th_percentile":12621.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11375.33,"10th_percentile":11375.33,"90th_percentile":11375.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":8174.48,"10th_percentile":8174.48,"90th_percentile":8174.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4706.9,"maximum":17632.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13368.19},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15462.94},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14802.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13970.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9356.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11216.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4706.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17632.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11718.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17099.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15144.96},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12910.5},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6401.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14720.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6851.04,"10th_percentile":6851.04,"90th_percentile":6851.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14180.72,"10th_percentile":14180.72,"90th_percentile":14180.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2864.13,"10th_percentile":2864.13,"90th_percentile":2864.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3731.26,"10th_percentile":3731.26,"90th_percentile":3731.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3713.1,"10th_percentile":3713.1,"90th_percentile":3713.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11725.26,"10th_percentile":11725.26,"90th_percentile":11725.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6990.86,"10th_percentile":6990.86,"90th_percentile":6990.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4788.01,"10th_percentile":4788.01,"90th_percentile":4891.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Mcc","code_information":[{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10054.13,"maximum":37662.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28554.99},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33029.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31617.92},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23959.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10054.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37662.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25031.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36524.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32350.24},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27577.34},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13673.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31444.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":26399.5,"10th_percentile":26399.5,"90th_percentile":26399.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13788.01,"10th_percentile":13788.01,"90th_percentile":13788.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14123.41,"10th_percentile":14123.41,"90th_percentile":14150.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14123.41,"10th_percentile":12076.8,"90th_percentile":14145.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12828.07,"10th_percentile":12828.07,"90th_percentile":12828.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Cc","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5504.3,"maximum":20619.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15632.87},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18082.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17309.72},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16337.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10942.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13117.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5504.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20619.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19995.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17710.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15097.64},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17214.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6043.08,"10th_percentile":6043.08,"90th_percentile":6043.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7709.23,"10th_percentile":7709.23,"90th_percentile":7709.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10572.2,"10th_percentile":10572.2,"90th_percentile":10572.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15302.5,"10th_percentile":15302.5,"90th_percentile":15302.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":215.11,"10th_percentile":215.11,"90th_percentile":215.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment Without Cc/Mcc","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3780.46,"maximum":14161.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10736.97},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12419.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11888.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11220.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7515.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9009.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3780.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14161.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9412.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13733.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.03},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10369.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5141.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11823.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5475.46,"10th_percentile":5475.46,"90th_percentile":5475.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":3519.98,"10th_percentile":3519.98,"90th_percentile":3519.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","code_information":[{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9607.11,"maximum":35988.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27285.39},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31560.93},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30212.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28515.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19098.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22894.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9607.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35988.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23918.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34900.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30911.9},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26351.21},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13065.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30046.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13126.06,"10th_percentile":13126.06,"90th_percentile":13126.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","code_information":[{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5588.86,"maximum":20935.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15873.07},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18360.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17575.68},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16588.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13318.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5588.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20935.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13914.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20303.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17982.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15329.62},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7600.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7912.93,"10th_percentile":7912.93,"90th_percentile":7912.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":117249.73,"maximum":439219.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":333003.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385184.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368723.14},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348013.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":233083.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279413.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117249.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":439219.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291917.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":425942.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":377263.34},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":321602.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159459.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366702.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","code_information":[{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39390.04,"maximum":147555.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111872.6},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129402.68},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123872.53},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116915.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78304.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93869.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39390.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":147555.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98069.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143095.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126741.61},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108042.38},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53570.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123193.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","code_information":[{"code":"929","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17687.54,"maximum":66257.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50234.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58106.45},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55623.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52499.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35161.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42150.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17687.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66257.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44036.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64254.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56911.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48514.91},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24055.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55318.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","code_information":[{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21385.63,"maximum":80110.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60737.84},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70255.26},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67252.83},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63475.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42512.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50963.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21385.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80110.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53243.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77689.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68810.51},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58658.33},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29084.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66884.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn Without Skin Graft Or Inhalation Injury","code_information":[{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12139.87,"maximum":45476.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34478.73},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39881.43},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.06},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36032.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28930.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12139.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45476.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30224.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44101.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39061.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33298.27},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16510.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37967.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive Burns","code_information":[{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11312.82,"maximum":42378.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32129.82},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37164.46},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35576.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33578.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22489.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26959.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11312.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42378.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28165.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41097.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36400.2},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31029.78},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15385.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35381.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","code_information":[{"code":"939","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19926.5,"maximum":74644.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56593.71},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65461.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62664.2},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59144.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39612.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47486.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19926.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74644.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49611.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72388.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64115.6},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27100.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62320.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","code_information":[{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12833.47,"maximum":48074.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36448.63},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42160.01},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40358.26},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38091.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25511.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30583.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12833.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48074.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31951.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46621.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41293.02},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35200.72},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17453.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40137.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6052.34,"10th_percentile":6052.34,"90th_percentile":6052.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16379.86,"10th_percentile":16379.86,"90th_percentile":16379.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","code_information":[{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11135.44,"maximum":41713.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31626.04},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36581.74},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35018.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33051.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22136.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26536.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11135.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41713.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27723.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40452.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35829.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30543.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15144.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34826.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation With Cc/Mcc","code_information":[{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8504.38,"maximum":31857.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24153.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.29},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26744.32},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25242.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16906.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20266.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8504.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31857.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21173.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30894.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27363.76},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23326.56},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11565.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26597.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation Without Cc/Mcc","code_information":[{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6297.84,"maximum":23591.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17886.64},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20689.42},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19805.24},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18692.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6297.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23591.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15679.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22878.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20263.96},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17274.25},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8565.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19696.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms With Mcc","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6971.12,"maximum":26113.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19798.83},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22901.25},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21922.54},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20691.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13858.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16612.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6971.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26113.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17356.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25324.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22430.3},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19120.97},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9480.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21802.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20060.86,"10th_percentile":20060.86,"90th_percentile":20060.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7841.8,"10th_percentile":7841.8,"90th_percentile":7841.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9961.36,"10th_percentile":9961.36,"90th_percentile":9994.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":26457.47,"10th_percentile":26457.47,"90th_percentile":26457.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":546.15,"10th_percentile":546.15,"90th_percentile":546.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4396.07,"maximum":16467.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12485.4},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.82},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13824.64},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13048.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8739.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10476.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4396.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16467.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15969.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.84},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12057.93},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5978.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13748.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4955.22,"10th_percentile":4577.49,"90th_percentile":7335.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12391.82,"10th_percentile":12391.82,"90th_percentile":12391.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6051.94,"10th_percentile":6051.94,"90th_percentile":6105.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":6821.66,"10th_percentile":6821.66,"90th_percentile":6821.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11849.17,"10th_percentile":11849.17,"90th_percentile":11849.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":410.07,"10th_percentile":407.87,"90th_percentile":4283.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4790.48,"10th_percentile":4790.48,"90th_percentile":4790.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare With Cc/Mcc","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6533.43,"maximum":24474.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18555.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21463.38},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20546.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19392.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12987.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15569.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6533.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24474.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16266.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23734.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.0},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17920.45},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":43495.83,"10th_percentile":43495.83,"90th_percentile":43495.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11180.0,"10th_percentile":11180.0,"90th_percentile":11180.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":83475.0,"10th_percentile":83475.0,"90th_percentile":83475.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4627.24,"10th_percentile":4627.24,"90th_percentile":4627.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33596.24,"10th_percentile":33596.24,"90th_percentile":33596.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare Without Cc/Mcc","code_information":[{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3447.11,"maximum":12912.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":9790.24},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11324.34},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10840.38},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10231.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6852.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8214.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3447.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12912.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8582.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12522.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.46},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9455.05},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4688.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10780.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Factors Influencing Health Status","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3053.36,"maximum":11437.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":8671.93},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10030.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9602.12},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9062.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6069.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7276.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3053.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11437.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7601.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11092.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9824.52},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8375.03},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4152.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9903.83,"10th_percentile":9903.83,"90th_percentile":9903.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":6189.94,"10th_percentile":6189.94,"90th_percentile":6189.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4364.37,"10th_percentile":4364.37,"90th_percentile":4369.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4606.85,"10th_percentile":4136.25,"90th_percentile":4629.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8540.72,"10th_percentile":8540.72,"90th_percentile":8540.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3936.7,"10th_percentile":3430.25,"90th_percentile":4630.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy For Multiple Significant Trauma","code_information":[{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36964.93,"maximum":138471.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104984.97},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121435.78},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116246.1},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109716.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73483.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88089.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36964.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":138471.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92031.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134285.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118938.54},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101390.56},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50272.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115609.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20665.12,"maximum":77411.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58691.51},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67888.28},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64987.01},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61336.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41080.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49246.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20665.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77411.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51450.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75071.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66492.21},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56682.07},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28104.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64630.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29194.93,"10th_percentile":29194.93,"90th_percentile":33463.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28835.76,"10th_percentile":28835.76,"90th_percentile":28835.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Mcc","code_information":[{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41845.91,"maximum":156755.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":118847.58},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137470.62},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":131595.67},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124204.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83186.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99721.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41845.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":156755.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104183.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152017.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134643.63},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114778.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56910.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130874.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Cc","code_information":[{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23141.32,"maximum":86687.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65724.2},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76022.97},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72774.05},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68686.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46003.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55147.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23141.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86687.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57615.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84067.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74459.61},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63473.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31472.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72375.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16168.0,"maximum":60565.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45919.13},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53114.51},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50844.61},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47988.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32140.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38529.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16168.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60565.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40253.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58734.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52022.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44346.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21988.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50565.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Mcc","code_information":[{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15013.1,"maximum":56239.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42639.08},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49320.49},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47212.73},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44560.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29844.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35777.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15013.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56239.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37378.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54539.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48306.25},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41179.23},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20417.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46953.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Cc","code_information":[{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8416.52,"maximum":31528.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23903.96},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27649.64},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26468.0},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24981.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16731.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8416.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31528.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20954.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30575.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27081.04},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23085.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11446.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26322.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11416.32,"10th_percentile":11416.32,"90th_percentile":11416.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5164.9,"maximum":19347.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14668.98},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16967.56},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16242.44},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10267.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12308.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5164.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19347.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12859.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18762.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16618.64},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.75},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7024.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16153.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures With Mcc","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33616.11,"maximum":125926.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95473.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110434.37},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105714.85},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99777.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66826.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80109.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33616.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":125926.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83694.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122119.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108163.37},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92205.14},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45717.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105135.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures Without Mcc","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14483.71,"maximum":54256.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41135.53},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47581.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45547.9},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42989.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28792.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34515.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14483.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54256.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36060.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46602.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39727.16},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19697.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45298.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Mcc","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15848.93,"maximum":59370.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45012.94},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52066.33},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49841.22},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47041.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31506.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37769.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15848.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59370.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39459.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57575.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50995.62},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43471.82},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21554.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49568.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23167.5,"10th_percentile":23167.5,"90th_percentile":23167.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Cc","code_information":[{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7111.7,"maximum":26640.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20198.12},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23363.1},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22364.65},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21108.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14137.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16947.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26640.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25835.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22882.65},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19506.59},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9671.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22242.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition Without Cc/Mcc","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4957.32,"maximum":18570.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14079.41},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16285.61},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15589.63},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14714.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9854.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11813.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4957.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18570.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12342.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18008.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15950.71},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13597.37},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6741.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15504.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Or Without Other Related Condition","code_information":[{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7126.53,"maximum":26696.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20240.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23411.81},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22411.28},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21152.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16983.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7126.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26696.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17742.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25889.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22930.36},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19547.26},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9692.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22288.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25765.78,"maximum":96519.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73178.0},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84644.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81027.39},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76476.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51220.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61401.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25765.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96519.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64149.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93601.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82904.11},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70672.58},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35041.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80583.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36853.36,"10th_percentile":36853.36,"90th_percentile":36853.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"1 through 10","median_amount":43059.3,"10th_percentile":43059.3,"90th_percentile":43059.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36861.66,"10th_percentile":36861.66,"90th_percentile":36861.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35322.34,"10th_percentile":35322.34,"90th_percentile":36820.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27560.59,"10th_percentile":27560.59,"90th_percentile":27560.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13501.25,"maximum":50575.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38345.22},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44353.8},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42458.3},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40073.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32174.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13501.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50575.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33614.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49047.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43441.7},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37032.39},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18361.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42225.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18008.26,"10th_percentile":18008.26,"90th_percentile":18008.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21255.37,"10th_percentile":21255.37,"90th_percentile":21255.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18595.23,"10th_percentile":18595.23,"90th_percentile":18595.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9412.71,"maximum":35260.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26733.26},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30922.27},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29600.78},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18711.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22431.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9412.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35260.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23434.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34194.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30286.38},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25817.98},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12801.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29438.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12936.37,"10th_percentile":12936.37,"90th_percentile":12936.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12302.36,"10th_percentile":12302.36,"90th_percentile":12302.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18827.61,"maximum":70528.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53472.75},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61851.76},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59208.47},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55882.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37427.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44867.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18827.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70528.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46875.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68396.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60579.83},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51641.99},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25605.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58883.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31895.72,"10th_percentile":31895.72,"90th_percentile":31895.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23594.49,"10th_percentile":23594.49,"90th_percentile":23594.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9026.09,"maximum":33811.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25635.23},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29652.19},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28384.97},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26790.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17943.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21509.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9026.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33811.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22472.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32789.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29042.41},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24757.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12275.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28229.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12862.51,"10th_percentile":12862.51,"90th_percentile":12862.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6585.6,"maximum":24669.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18703.92},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21634.77},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20710.18},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19546.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13091.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15693.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6585.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24669.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16396.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23924.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21189.86},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18063.55},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8956.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20596.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","code_information":[{"code":"455","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70401.2,"maximum":70401.2,"payers_information":[{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70401.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"0764","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1083.81,"10th_percentile":1083.81,"90th_percentile":1083.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7191.5,"10th_percentile":4106.0,"90th_percentile":12413.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":3388.0,"10th_percentile":304.92,"90th_percentile":10987.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1171.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1111.88,"10th_percentile":1111.88,"90th_percentile":1111.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":28674.26,"10th_percentile":28674.26,"90th_percentile":28674.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14231.73,"10th_percentile":14231.73,"90th_percentile":14231.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3570.25,"10th_percentile":3570.25,"90th_percentile":3570.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":16825.53,"10th_percentile":16825.53,"90th_percentile":16825.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3288.59,"10th_percentile":3288.59,"90th_percentile":7489.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":10688.21,"10th_percentile":10688.21,"90th_percentile":10688.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7546.65,"10th_percentile":7546.65,"90th_percentile":7546.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":18032.99,"10th_percentile":18032.99,"90th_percentile":18032.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":11139.38,"10th_percentile":5991.0,"90th_percentile":29888.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":806.81,"10th_percentile":742.85,"90th_percentile":1607.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7006.5,"10th_percentile":3289.77,"90th_percentile":10543.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":42413.52,"10th_percentile":42413.52,"90th_percentile":42413.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Injection,onabotulinumtoxinA","code_information":[{"code":"0902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":3658.57,"10th_percentile":3658.57,"90th_percentile":3658.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cath coronary drug-delivery","code_information":[{"code":"2050","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12998.76,"10th_percentile":12998.76,"90th_percentile":12998.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12024.06,"10th_percentile":12024.06,"90th_percentile":12024.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1075.0,"10th_percentile":1075.0,"90th_percentile":1075.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":130.35,"10th_percentile":130.35,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"12","median_amount":125.0,"10th_percentile":83.94,"90th_percentile":948.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":202.23,"10th_percentile":202.23,"90th_percentile":202.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":102.21,"10th_percentile":102.21,"90th_percentile":102.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":255.38,"10th_percentile":255.38,"90th_percentile":255.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":93.0,"10th_percentile":93.0,"90th_percentile":93.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":133.01,"10th_percentile":133.01,"90th_percentile":357.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":132.85,"10th_percentile":132.85,"90th_percentile":132.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":108.75,"10th_percentile":108.75,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":128.96,"10th_percentile":128.96,"90th_percentile":128.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":88.25,"10th_percentile":88.25,"90th_percentile":88.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"25","median_amount":86.88,"10th_percentile":69.5,"90th_percentile":192.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":208.56,"10th_percentile":125.0,"90th_percentile":257.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":112.5,"10th_percentile":112.5,"90th_percentile":112.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":45.37,"10th_percentile":45.37,"90th_percentile":45.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":141.6,"10th_percentile":141.6,"90th_percentile":141.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":101.94,"10th_percentile":74.64,"90th_percentile":122.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":89.42,"10th_percentile":89.42,"90th_percentile":89.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":97.09,"10th_percentile":97.09,"90th_percentile":97.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":174.49,"10th_percentile":174.49,"90th_percentile":174.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.77,"10th_percentile":24.77,"90th_percentile":24.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":53.56,"10th_percentile":53.56,"90th_percentile":70.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":77.88,"10th_percentile":77.88,"90th_percentile":77.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":88.11,"10th_percentile":88.11,"90th_percentile":88.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":157.17,"10th_percentile":157.17,"90th_percentile":157.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":362.41,"10th_percentile":227.27,"90th_percentile":1098.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":82.5,"10th_percentile":64.69,"90th_percentile":518.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":53.56,"10th_percentile":53.56,"90th_percentile":53.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1079.2,"10th_percentile":1079.2,"90th_percentile":1079.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"84","median_amount":81.86,"10th_percentile":55.05,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":159.05,"10th_percentile":71.09,"90th_percentile":161.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"56","median_amount":522.19,"10th_percentile":185.55,"90th_percentile":1191.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"71","median_amount":661.0,"10th_percentile":194.63,"90th_percentile":736.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"98","median_amount":77.88,"10th_percentile":56.24,"90th_percentile":180.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":809.13,"10th_percentile":809.13,"90th_percentile":809.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":81.24,"10th_percentile":49.39,"90th_percentile":230.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":561.85,"10th_percentile":438.16,"90th_percentile":1054.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":80.79,"10th_percentile":52.23,"90th_percentile":249.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"14","median_amount":313.82,"10th_percentile":294.54,"90th_percentile":488.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"16","median_amount":491.76,"10th_percentile":491.76,"90th_percentile":1330.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1139.95,"10th_percentile":644.65,"90th_percentile":1275.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":161.45,"10th_percentile":52.37,"90th_percentile":270.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"47","median_amount":74.17,"10th_percentile":45.37,"90th_percentile":230.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":100.67,"10th_percentile":100.67,"90th_percentile":100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":178.37,"10th_percentile":178.37,"90th_percentile":178.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":587.03,"10th_percentile":73.06,"90th_percentile":600.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"114","median_amount":77.88,"10th_percentile":54.84,"90th_percentile":227.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"73","median_amount":160.17,"10th_percentile":51.25,"90th_percentile":163.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"21","median_amount":661.0,"10th_percentile":586.0,"90th_percentile":1253.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"11","median_amount":518.41,"10th_percentile":376.26,"90th_percentile":1057.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"51","median_amount":74.17,"10th_percentile":49.72,"90th_percentile":270.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":499.31,"10th_percentile":77.0,"90th_percentile":1010.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"204","median_amount":459.4,"10th_percentile":138.1,"90th_percentile":1106.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"300","median_amount":74.17,"10th_percentile":53.43,"90th_percentile":149.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":107.47,"10th_percentile":107.47,"90th_percentile":107.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"76","median_amount":125.0,"10th_percentile":52.37,"90th_percentile":249.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":55.58,"10th_percentile":44.75,"90th_percentile":163.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"53","median_amount":762.3,"10th_percentile":594.9,"90th_percentile":1307.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"14","median_amount":2522.25,"10th_percentile":723.12,"90th_percentile":5990.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"296","median_amount":107.48,"10th_percentile":66.43,"90th_percentile":272.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"137","median_amount":280.93,"10th_percentile":189.29,"90th_percentile":508.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"206","median_amount":1365.0,"10th_percentile":505.68,"90th_percentile":3073.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"374","median_amount":1367.0,"10th_percentile":736.97,"90th_percentile":3045.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"243","median_amount":122.19,"10th_percentile":66.44,"90th_percentile":282.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1494.0,"10th_percentile":1494.0,"90th_percentile":1494.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1257.0,"10th_percentile":910.16,"90th_percentile":2534.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":2537.3,"10th_percentile":2537.3,"90th_percentile":2537.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"80","median_amount":133.77,"10th_percentile":72.32,"90th_percentile":304.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"45","median_amount":1464.04,"10th_percentile":705.21,"90th_percentile":3140.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"54","median_amount":216.8,"10th_percentile":80.79,"90th_percentile":345.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":282.57,"10th_percentile":246.64,"90th_percentile":559.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"139","median_amount":657.63,"10th_percentile":543.65,"90th_percentile":1079.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"59","median_amount":1543.01,"10th_percentile":736.54,"90th_percentile":2843.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"25","median_amount":1426.25,"10th_percentile":899.66,"90th_percentile":3654.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"192","median_amount":282.57,"10th_percentile":142.87,"90th_percentile":518.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"124","median_amount":125.48,"10th_percentile":63.47,"90th_percentile":267.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":438.7,"10th_percentile":257.0,"90th_percentile":669.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":184.6,"10th_percentile":70.92,"90th_percentile":631.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":310.11,"10th_percentile":224.06,"90th_percentile":421.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"13","median_amount":1703.03,"10th_percentile":550.17,"90th_percentile":3195.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":353.94,"10th_percentile":353.94,"90th_percentile":353.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"259","median_amount":122.24,"10th_percentile":67.25,"90th_percentile":293.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"666","median_amount":295.31,"10th_percentile":221.99,"90th_percentile":548.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"156","median_amount":1940.0,"10th_percentile":999.5,"90th_percentile":2164.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"53","median_amount":1468.06,"10th_percentile":806.92,"90th_percentile":3471.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"81","median_amount":144.38,"10th_percentile":65.47,"90th_percentile":307.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"20","median_amount":1348.35,"10th_percentile":471.75,"90th_percentile":3877.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"927","median_amount":1091.85,"10th_percentile":364.13,"90th_percentile":2567.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"721","median_amount":116.78,"10th_percentile":65.71,"90th_percentile":300.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":199.29,"10th_percentile":199.29,"90th_percentile":205.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":279.89,"10th_percentile":228.49,"90th_percentile":316.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"516","median_amount":282.58,"10th_percentile":172.27,"90th_percentile":518.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"96","median_amount":268.73,"10th_percentile":177.88,"90th_percentile":491.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"182","median_amount":1327.05,"10th_percentile":891.0,"90th_percentile":2435.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1738.23,"10th_percentile":714.78,"90th_percentile":3717.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"11","median_amount":4219.67,"10th_percentile":967.66,"90th_percentile":10000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"115","median_amount":295.05,"10th_percentile":114.79,"90th_percentile":609.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. 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Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"124","median_amount":313.14,"10th_percentile":142.83,"90th_percentile":533.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":357.1,"10th_percentile":208.54,"90th_percentile":523.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"35","median_amount":3952.92,"10th_percentile":1974.19,"90th_percentile":7024.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":317.71,"10th_percentile":191.84,"90th_percentile":492.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":908.92,"10th_percentile":411.33,"90th_percentile":1112.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"170","median_amount":1435.85,"10th_percentile":848.24,"90th_percentile":2271.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"46","median_amount":3625.41,"10th_percentile":2272.84,"90th_percentile":6054.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4093.05,"10th_percentile":2003.34,"90th_percentile":9580.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"158","median_amount":727.87,"10th_percentile":282.27,"90th_percentile":1124.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"46","median_amount":318.27,"10th_percentile":109.93,"90th_percentile":629.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1107.16,"10th_percentile":1107.16,"90th_percentile":1107.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":233.94,"10th_percentile":160.42,"90th_percentile":607.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":500.84,"10th_percentile":344.57,"90th_percentile":749.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":7173.5,"10th_percentile":7173.5,"90th_percentile":7173.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"16","median_amount":3783.35,"10th_percentile":2241.99,"90th_percentile":9408.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"117","median_amount":335.24,"10th_percentile":122.62,"90th_percentile":612.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"703","median_amount":730.37,"10th_percentile":472.27,"90th_percentile":1125.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"84","median_amount":4266.0,"10th_percentile":2878.0,"90th_percentile":4455.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"46","median_amount":3675.9,"10th_percentile":1950.08,"90th_percentile":9682.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":301.45,"10th_percentile":183.25,"90th_percentile":469.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"21","median_amount":1988.74,"10th_percentile":648.34,"90th_percentile":4705.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"730","median_amount":2865.55,"10th_percentile":1242.32,"90th_percentile":5897.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":3516.81,"10th_percentile":3516.81,"90th_percentile":3516.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"374","median_amount":300.19,"10th_percentile":123.0,"90th_percentile":569.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":380.28,"10th_percentile":339.05,"90th_percentile":914.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"539","median_amount":732.9,"10th_percentile":422.28,"90th_percentile":1124.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"92","median_amount":639.74,"10th_percentile":387.22,"90th_percentile":1056.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"45","median_amount":3239.6,"10th_percentile":1859.23,"90th_percentile":8743.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3792.74,"10th_percentile":2306.98,"90th_percentile":6990.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":7461.08,"10th_percentile":7461.08,"90th_percentile":7461.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":454.55,"10th_percentile":200.85,"90th_percentile":869.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"61","median_amount":1507.6,"10th_percentile":756.95,"90th_percentile":2768.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"57","median_amount":6614.53,"10th_percentile":2880.63,"90th_percentile":15377.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"79","median_amount":3928.0,"10th_percentile":1950.0,"90th_percentile":10237.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":499.54,"10th_percentile":265.06,"90th_percentile":1022.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":602.22,"10th_percentile":433.57,"90th_percentile":1114.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"20","median_amount":7102.17,"10th_percentile":4251.06,"90th_percentile":14730.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":672.87,"10th_percentile":672.87,"90th_percentile":672.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1394.4,"10th_percentile":1161.44,"90th_percentile":2687.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"60","median_amount":2292.0,"10th_percentile":1425.7,"90th_percentile":5246.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"18","median_amount":6680.54,"10th_percentile":3031.5,"90th_percentile":13043.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":440.0,"10th_percentile":440.0,"90th_percentile":440.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":12046.89,"10th_percentile":6859.01,"90th_percentile":13942.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"44","median_amount":1375.51,"10th_percentile":822.8,"90th_percentile":2686.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":566.14,"10th_percentile":318.06,"90th_percentile":965.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1776.87,"10th_percentile":1776.87,"90th_percentile":1776.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":676.29,"10th_percentile":676.29,"90th_percentile":676.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":9756.73,"10th_percentile":5080.02,"90th_percentile":21042.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":472.55,"10th_percentile":195.74,"90th_percentile":763.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"254","median_amount":1377.05,"10th_percentile":835.34,"90th_percentile":2786.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"28","median_amount":4869.53,"10th_percentile":3981.0,"90th_percentile":11362.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4423.01,"10th_percentile":3308.48,"90th_percentile":9982.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":507.73,"10th_percentile":466.74,"90th_percentile":1254.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6428.68,"10th_percentile":2744.58,"90th_percentile":13399.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"209","median_amount":5348.43,"10th_percentile":2404.92,"90th_percentile":14067.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"89","median_amount":438.04,"10th_percentile":168.38,"90th_percentile":924.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":244.18,"10th_percentile":244.18,"90th_percentile":244.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1246.11,"10th_percentile":1246.11,"90th_percentile":1246.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"189","median_amount":1408.38,"10th_percentile":713.07,"90th_percentile":2832.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"29","median_amount":984.05,"10th_percentile":615.59,"90th_percentile":2561.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7215.41,"10th_percentile":7062.2,"90th_percentile":12998.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5267.9,"10th_percentile":5267.9,"90th_percentile":7694.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":655.8,"10th_percentile":655.8,"90th_percentile":760.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1764.32,"10th_percentile":1505.51,"90th_percentile":2937.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":12802.94,"10th_percentile":11697.76,"90th_percentile":25453.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":5139.0,"10th_percentile":3602.82,"90th_percentile":10283.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1241.62,"10th_percentile":1241.62,"90th_percentile":1241.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":3971.75,"10th_percentile":3971.75,"90th_percentile":3971.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":8390.2,"10th_percentile":8390.2,"90th_percentile":8390.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":945.77,"10th_percentile":945.77,"90th_percentile":945.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4924.63,"10th_percentile":4924.63,"90th_percentile":6440.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":14812.75,"10th_percentile":14812.75,"90th_percentile":14812.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":1635.28,"10th_percentile":1295.2,"90th_percentile":7201.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1101.67,"10th_percentile":1101.67,"90th_percentile":1101.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.81,"10th_percentile":505.81,"90th_percentile":505.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":5673.28,"10th_percentile":5673.28,"90th_percentile":5673.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.48,"10th_percentile":505.48,"90th_percentile":557.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"41","median_amount":2113.9,"10th_percentile":1209.22,"90th_percentile":9821.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":11031.3,"10th_percentile":7495.73,"90th_percentile":11031.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17855.22,"10th_percentile":17855.22,"90th_percentile":17855.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":695.34,"10th_percentile":695.34,"90th_percentile":695.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"27","median_amount":12998.65,"10th_percentile":5212.9,"90th_percentile":18056.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1053.84,"10th_percentile":673.93,"90th_percentile":1692.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":1820.81,"10th_percentile":1250.49,"90th_percentile":2846.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1614.82,"10th_percentile":1614.82,"90th_percentile":1614.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma Response with Critical Care","code_information":[{"code":"5045","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3518.86,"10th_percentile":3518.86,"90th_percentile":3518.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":11451.0,"10th_percentile":11451.0,"90th_percentile":11451.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.64,"10th_percentile":132.64,"90th_percentile":132.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1735.41,"10th_percentile":1735.41,"90th_percentile":1735.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5253.0,"10th_percentile":5253.0,"90th_percentile":5253.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":20770.36,"10th_percentile":20770.36,"90th_percentile":20770.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":17286.16,"10th_percentile":15888.33,"90th_percentile":21467.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":546.17,"10th_percentile":546.17,"90th_percentile":546.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2677.59,"10th_percentile":2677.59,"90th_percentile":2677.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":16918.28,"10th_percentile":16918.28,"90th_percentile":16918.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":159.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":482.34,"10th_percentile":247.49,"90th_percentile":777.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1617.38,"10th_percentile":1053.6,"90th_percentile":3585.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":1467.0,"10th_percentile":538.02,"90th_percentile":2235.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.19,"10th_percentile":216.19,"90th_percentile":216.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3092.2,"10th_percentile":3092.2,"90th_percentile":3092.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":428.42,"10th_percentile":428.42,"90th_percentile":428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1471.74,"10th_percentile":1471.74,"90th_percentile":1471.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":200.87,"10th_percentile":200.87,"90th_percentile":200.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":896.81,"10th_percentile":896.81,"90th_percentile":896.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":551.57,"10th_percentile":551.57,"90th_percentile":551.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1540.57,"10th_percentile":1272.18,"90th_percentile":2670.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":310.17,"10th_percentile":159.05,"90th_percentile":753.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":287.77,"10th_percentile":287.77,"90th_percentile":287.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":167.98,"10th_percentile":163.06,"90th_percentile":176.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"71","median_amount":331.33,"10th_percentile":200.98,"90th_percentile":735.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2026.2,"10th_percentile":905.98,"90th_percentile":3750.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1299.83,"10th_percentile":1299.83,"90th_percentile":1299.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":159.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":349.5,"10th_percentile":349.5,"90th_percentile":349.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"29","median_amount":1460.0,"10th_percentile":399.44,"90th_percentile":1988.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":578.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"25","median_amount":331.93,"10th_percentile":159.89,"90th_percentile":726.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.58,"10th_percentile":177.88,"90th_percentile":439.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"29","median_amount":1441.92,"10th_percentile":1232.97,"90th_percentile":2159.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":164.58,"10th_percentile":143.07,"90th_percentile":495.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":949.59,"10th_percentile":493.86,"90th_percentile":1874.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"14","median_amount":3470.0,"10th_percentile":1887.6,"90th_percentile":4140.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"47","median_amount":3306.5,"10th_percentile":1467.0,"90th_percentile":7285.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":446.02,"10th_percentile":223.01,"90th_percentile":1242.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2091.0,"10th_percentile":2091.0,"90th_percentile":8399.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":240.63,"10th_percentile":240.63,"90th_percentile":240.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":2071.67,"10th_percentile":2071.67,"90th_percentile":6095.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":605.96,"10th_percentile":605.96,"90th_percentile":605.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1303.41,"10th_percentile":1071.38,"90th_percentile":2517.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2309.11,"10th_percentile":2309.11,"90th_percentile":5605.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2175.77,"10th_percentile":2175.77,"90th_percentile":2175.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":905.36,"10th_percentile":404.92,"90th_percentile":1550.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":420.14,"10th_percentile":420.14,"90th_percentile":585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":582.51,"10th_percentile":582.51,"90th_percentile":582.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":446.02,"10th_percentile":167.26,"90th_percentile":1115.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"150","median_amount":808.24,"10th_percentile":404.12,"90th_percentile":1728.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1964.72,"10th_percentile":1253.98,"90th_percentile":8266.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1651.39,"10th_percentile":1170.44,"90th_percentile":4112.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":72.2,"10th_percentile":72.2,"90th_percentile":72.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2472.76,"10th_percentile":1653.46,"90th_percentile":3709.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"47","median_amount":2932.73,"10th_percentile":1157.25,"90th_percentile":5680.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":178.51,"10th_percentile":162.04,"90th_percentile":836.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":522.26,"10th_percentile":296.1,"90th_percentile":650.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"115","median_amount":806.09,"10th_percentile":384.63,"90th_percentile":1781.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":529.28,"10th_percentile":329.77,"90th_percentile":3810.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"12","median_amount":2419.44,"10th_percentile":1880.66,"90th_percentile":3510.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":340.55,"10th_percentile":340.55,"90th_percentile":340.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1608.43,"10th_percentile":1608.43,"90th_percentile":1608.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1128.84,"10th_percentile":1128.84,"90th_percentile":1145.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3547.92,"10th_percentile":3547.92,"90th_percentile":3547.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":305.81,"10th_percentile":305.81,"90th_percentile":305.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3478.5,"10th_percentile":1582.74,"90th_percentile":3910.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":431.86,"10th_percentile":431.86,"90th_percentile":1531.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2220.28,"10th_percentile":2220.28,"90th_percentile":5751.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4311.3,"10th_percentile":4311.3,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8885.84,"10th_percentile":8885.84,"90th_percentile":8885.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3122.0,"10th_percentile":3122.0,"90th_percentile":3122.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":13077.63,"10th_percentile":13077.63,"90th_percentile":13077.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2671.75,"10th_percentile":2671.75,"90th_percentile":2671.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5074.47,"10th_percentile":5074.47,"90th_percentile":5074.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2781.35,"10th_percentile":2781.35,"90th_percentile":2781.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"18","median_amount":2781.35,"10th_percentile":2597.36,"90th_percentile":3152.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7141.5,"10th_percentile":7141.5,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6234.7,"10th_percentile":6234.7,"90th_percentile":6234.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":7295.62,"10th_percentile":6219.4,"90th_percentile":9270.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2709.16,"10th_percentile":2385.9,"90th_percentile":3211.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Skin Procedures","code_information":[{"code":"5055","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":21096.38,"10th_percentile":21096.38,"90th_percentile":21096.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4012.58,"10th_percentile":4012.58,"90th_percentile":4012.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3708.5,"10th_percentile":3708.5,"90th_percentile":3708.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":555.28,"10th_percentile":555.28,"90th_percentile":555.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":670.49,"10th_percentile":417.67,"90th_percentile":717.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2660.28,"10th_percentile":346.02,"90th_percentile":3335.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"11","median_amount":2428.2,"10th_percentile":812.43,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":8763.16,"10th_percentile":8763.16,"90th_percentile":8763.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":277.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":843.08,"10th_percentile":843.08,"90th_percentile":843.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1394.28,"10th_percentile":1340.6,"90th_percentile":1394.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3472.89,"10th_percentile":3472.89,"90th_percentile":3472.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":390.27,"10th_percentile":368.67,"90th_percentile":765.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":223.01,"10th_percentile":162.44,"90th_percentile":291.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"36","median_amount":711.67,"10th_percentile":684.27,"90th_percentile":786.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2752.0,"10th_percentile":2737.25,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1787.2,"10th_percentile":1787.2,"90th_percentile":1787.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":277.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4165.31,"10th_percentile":4165.31,"90th_percentile":4165.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":1899.73,"10th_percentile":1678.98,"90th_percentile":4627.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":555.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"19","median_amount":718.97,"10th_percentile":569.33,"90th_percentile":765.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":580.72,"10th_percentile":580.72,"90th_percentile":580.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":829.13,"10th_percentile":646.54,"90th_percentile":845.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":1438.49,"10th_percentile":1237.0,"90th_percentile":1664.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4106.0,"10th_percentile":3227.72,"90th_percentile":4314.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"33","median_amount":3388.0,"10th_percentile":3049.2,"90th_percentile":4715.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5082.0,"10th_percentile":5082.0,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":817.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":552.75,"10th_percentile":552.75,"90th_percentile":552.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":6636.64,"10th_percentile":2382.48,"90th_percentile":11924.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":548.84,"10th_percentile":548.84,"90th_percentile":548.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1735.6,"10th_percentile":1735.6,"90th_percentile":1735.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3227.52,"10th_percentile":3210.8,"90th_percentile":3357.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6652.99,"10th_percentile":6006.73,"90th_percentile":17992.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4466.55,"10th_percentile":4466.55,"90th_percentile":4466.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":1638.84,"10th_percentile":827.45,"90th_percentile":1738.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":432.62,"10th_percentile":432.62,"90th_percentile":432.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":5409.97,"10th_percentile":5409.97,"90th_percentile":5409.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":503.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"126","median_amount":1638.84,"10th_percentile":1344.84,"90th_percentile":1724.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"11","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":6934.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5897.36,"10th_percentile":4892.14,"90th_percentile":10583.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4787.07,"10th_percentile":4787.07,"90th_percentile":8134.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"95","median_amount":5768.72,"10th_percentile":3502.43,"90th_percentile":9898.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":552.75,"10th_percentile":323.26,"90th_percentile":754.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"58","median_amount":1582.7,"10th_percentile":1224.16,"90th_percentile":1682.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1337.3,"10th_percentile":1248.65,"90th_percentile":1752.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7919.8,"10th_percentile":7919.8,"90th_percentile":7919.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2894.91,"10th_percentile":2769.39,"90th_percentile":2894.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4589.0,"10th_percentile":4589.0,"90th_percentile":4589.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":6777.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":829.03,"10th_percentile":829.03,"90th_percentile":829.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":10259.11,"10th_percentile":10259.11,"90th_percentile":10259.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":705.96,"10th_percentile":705.96,"90th_percentile":705.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5671.66,"10th_percentile":5671.66,"90th_percentile":5671.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11776.44,"10th_percentile":11776.44,"90th_percentile":11776.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2894.91,"10th_percentile":2894.91,"90th_percentile":2894.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":6043.15,"10th_percentile":6043.15,"90th_percentile":6043.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"20","median_amount":2767.99,"10th_percentile":2551.91,"90th_percentile":2901.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7564.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11178.88,"10th_percentile":11178.88,"90th_percentile":11178.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5979.37,"10th_percentile":5979.37,"90th_percentile":5979.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":10001.77,"10th_percentile":6161.11,"90th_percentile":12751.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":761.53,"10th_percentile":754.84,"90th_percentile":1597.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2763.49,"10th_percentile":2507.82,"90th_percentile":2894.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2255.01,"10th_percentile":2255.01,"90th_percentile":2255.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":13100.63,"10th_percentile":13100.63,"90th_percentile":13100.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5370.7,"10th_percentile":5370.7,"90th_percentile":5370.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6256.5,"10th_percentile":6074.61,"90th_percentile":14746.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3962.02,"10th_percentile":3174.83,"90th_percentile":13768.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":12998.02,"10th_percentile":12998.02,"90th_percentile":31591.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11323.86,"10th_percentile":11323.86,"90th_percentile":11323.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":13263.51,"10th_percentile":13263.51,"90th_percentile":13263.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3885.19,"10th_percentile":3713.1,"90th_percentile":6695.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":14967.44,"10th_percentile":14967.44,"90th_percentile":14967.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"27","median_amount":3879.24,"10th_percentile":3622.47,"90th_percentile":6609.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":9306.0,"10th_percentile":9306.0,"90th_percentile":9306.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9823.21,"10th_percentile":9823.21,"90th_percentile":9823.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"21","median_amount":10931.08,"10th_percentile":8435.8,"90th_percentile":17837.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":557.74,"10th_percentile":557.74,"90th_percentile":561.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3880.25,"10th_percentile":3600.25,"90th_percentile":3973.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5092","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6052.99,"10th_percentile":6052.99,"90th_percentile":6052.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9577.5,"10th_percentile":9577.5,"90th_percentile":11973.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12523.53,"10th_percentile":12523.53,"90th_percentile":12523.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":20725.42,"10th_percentile":20725.42,"90th_percentile":20725.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6602.32,"10th_percentile":6602.32,"90th_percentile":6701.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":23536.5,"10th_percentile":23536.5,"90th_percentile":23536.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":19098.83,"10th_percentile":19098.83,"90th_percentile":19098.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":21060.39,"10th_percentile":15954.59,"90th_percentile":23172.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3085.31,"10th_percentile":3085.31,"90th_percentile":4501.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6699.48,"10th_percentile":6699.48,"90th_percentile":6699.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5093","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1620.0,"10th_percentile":1620.0,"90th_percentile":1620.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":17370.9,"10th_percentile":17370.9,"90th_percentile":17370.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":19139.22,"10th_percentile":16541.75,"90th_percentile":59396.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5094","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":57320.5,"10th_percentile":57320.5,"90th_percentile":57320.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":25082.78,"10th_percentile":21578.28,"90th_percentile":46766.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":28943.29,"10th_percentile":28943.29,"90th_percentile":28943.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":33816.39,"10th_percentile":33816.39,"90th_percentile":33816.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":53252.02,"10th_percentile":53252.02,"90th_percentile":53252.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6178.64,"10th_percentile":6178.64,"90th_percentile":17700.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":52453.07,"10th_percentile":52453.07,"90th_percentile":52453.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":64812.39,"10th_percentile":62403.57,"90th_percentile":66465.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6759.33,"10th_percentile":6759.33,"90th_percentile":6759.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17702.14,"10th_percentile":17702.14,"90th_percentile":17702.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":756.0,"10th_percentile":756.0,"90th_percentile":756.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":85.9,"10th_percentile":85.9,"90th_percentile":85.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":824.39,"10th_percentile":345.24,"90th_percentile":1191.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":467.04,"10th_percentile":467.04,"90th_percentile":467.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.7,"10th_percentile":260.7,"90th_percentile":441.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":318.06,"10th_percentile":318.06,"90th_percentile":318.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":844.93,"10th_percentile":844.93,"90th_percentile":844.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1106.15,"10th_percentile":1106.15,"90th_percentile":1106.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":322.83,"10th_percentile":322.83,"90th_percentile":322.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.91,"10th_percentile":483.91,"90th_percentile":483.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":789.19,"10th_percentile":789.19,"90th_percentile":789.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1240.94,"10th_percentile":1240.94,"90th_percentile":1240.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1226.12,"10th_percentile":1226.12,"90th_percentile":1226.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1075.87,"10th_percentile":675.84,"90th_percentile":1889.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":969.87,"10th_percentile":969.87,"90th_percentile":969.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8684.32,"10th_percentile":2760.75,"90th_percentile":13275.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":318.06,"10th_percentile":318.06,"90th_percentile":318.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1100.74,"10th_percentile":1100.74,"90th_percentile":1100.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3587.8,"10th_percentile":3587.8,"90th_percentile":3587.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":898.15,"10th_percentile":898.15,"90th_percentile":1000.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1517.47,"10th_percentile":1397.37,"90th_percentile":1618.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3803.7,"10th_percentile":3376.67,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"23","median_amount":3388.0,"10th_percentile":2350.0,"90th_percentile":6776.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":610.32,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":211.35,"10th_percentile":211.35,"90th_percentile":211.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":6920.45,"10th_percentile":6027.15,"90th_percentile":8148.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3171.49,"10th_percentile":3062.38,"90th_percentile":3189.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3380.44,"10th_percentile":3380.44,"90th_percentile":3380.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4224.38,"10th_percentile":4224.38,"90th_percentile":4224.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1570.08,"10th_percentile":1226.78,"90th_percentile":1627.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1347.23,"10th_percentile":1347.23,"90th_percentile":1347.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":9194.13,"10th_percentile":9194.13,"90th_percentile":9194.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"30","median_amount":1567.58,"10th_percentile":1324.78,"90th_percentile":1624.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7550.5,"10th_percentile":4455.78,"90th_percentile":9349.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5816.4,"10th_percentile":5756.33,"90th_percentile":7646.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6025.8,"10th_percentile":6025.8,"90th_percentile":6025.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":5064.21,"10th_percentile":2954.37,"90th_percentile":6535.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":903.92,"10th_percentile":307.45,"90th_percentile":1347.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1569.86,"10th_percentile":1250.46,"90th_percentile":1627.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1275.47,"10th_percentile":1275.47,"90th_percentile":1275.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1355.88,"10th_percentile":1347.23,"90th_percentile":1743.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":3064.29,"10th_percentile":2668.38,"90th_percentile":3282.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4821.0,"10th_percentile":3212.3,"90th_percentile":8492.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":3735.0,"10th_percentile":3169.6,"90th_percentile":6489.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":2419.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":14135.08,"10th_percentile":14135.08,"90th_percentile":16794.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.79,"10th_percentile":888.79,"90th_percentile":888.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3289.86,"10th_percentile":3289.86,"90th_percentile":3289.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6429.77,"10th_percentile":6429.77,"90th_percentile":6463.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11750.99,"10th_percentile":8687.0,"90th_percentile":12110.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3287.86,"10th_percentile":3078.54,"90th_percentile":3287.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3336.2,"10th_percentile":3336.2,"90th_percentile":3336.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":19824.56,"10th_percentile":19824.56,"90th_percentile":19824.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":20708.12,"10th_percentile":20708.12,"90th_percentile":20708.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"63","median_amount":3287.86,"10th_percentile":2988.54,"90th_percentile":3505.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"13","median_amount":10143.62,"10th_percentile":8153.71,"90th_percentile":19406.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":8004.58,"10th_percentile":8004.58,"90th_percentile":8004.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":12819.28,"10th_percentile":12819.28,"90th_percentile":12819.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"78","median_amount":9190.41,"10th_percentile":7379.93,"90th_percentile":16141.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1347.23,"10th_percentile":898.15,"90th_percentile":2191.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"40","median_amount":3147.99,"10th_percentile":2625.49,"90th_percentile":3536.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2568.76,"10th_percentile":2500.47,"90th_percentile":2568.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":14777.21,"10th_percentile":9930.85,"90th_percentile":21723.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":11111.8,"10th_percentile":11111.8,"90th_percentile":11111.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2856.53,"10th_percentile":2531.04,"90th_percentile":4552.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7024.97,"10th_percentile":6663.69,"90th_percentile":9254.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"14","median_amount":13102.91,"10th_percentile":8048.81,"90th_percentile":23625.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":9535.0,"10th_percentile":5639.85,"90th_percentile":17452.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7055.29,"10th_percentile":7055.29,"90th_percentile":7055.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":2333.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3538.83,"10th_percentile":3538.83,"90th_percentile":3538.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":24225.9,"10th_percentile":19205.78,"90th_percentile":35798.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2081.86,"10th_percentile":2081.86,"90th_percentile":2081.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14156.56,"10th_percentile":13728.65,"90th_percentile":14157.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":16112.52,"10th_percentile":16112.52,"90th_percentile":20269.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6963.69,"10th_percentile":6833.74,"90th_percentile":7329.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":26203.47,"10th_percentile":26203.47,"90th_percentile":26203.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":7849.17,"10th_percentile":7849.17,"90th_percentile":7849.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"61","median_amount":7231.74,"10th_percentile":6931.74,"90th_percentile":7326.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":23025.85,"10th_percentile":17314.0,"90th_percentile":28366.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17922.08,"10th_percentile":12820.62,"90th_percentile":27249.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3611.47,"10th_percentile":3611.47,"90th_percentile":4022.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":34077.79,"10th_percentile":34077.79,"90th_percentile":34077.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"79","median_amount":18702.09,"10th_percentile":13414.18,"90th_percentile":24441.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":3004.37,"10th_percentile":2045.66,"90th_percentile":4327.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"36","median_amount":7005.52,"10th_percentile":5780.59,"90th_percentile":7322.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5896.2,"10th_percentile":5505.94,"90th_percentile":7370.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"21","median_amount":22204.21,"10th_percentile":16801.17,"90th_percentile":30435.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4006.95,"10th_percentile":3978.71,"90th_percentile":4134.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":12895.18,"10th_percentile":12030.27,"90th_percentile":13188.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":14089.95,"10th_percentile":12830.59,"90th_percentile":15863.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":12049.48,"10th_percentile":10988.7,"90th_percentile":19052.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4174.34,"10th_percentile":4174.34,"90th_percentile":4174.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4740.03,"10th_percentile":4740.03,"90th_percentile":4740.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":28875.91,"10th_percentile":28875.91,"90th_percentile":28875.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":13116.76,"10th_percentile":13116.76,"90th_percentile":13116.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":25825.33,"10th_percentile":25825.33,"90th_percentile":38948.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":18558.68,"10th_percentile":18270.15,"90th_percentile":20456.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":34724.82,"10th_percentile":34724.82,"90th_percentile":34724.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":13108.44,"10th_percentile":12672.51,"90th_percentile":13192.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1337.17,"10th_percentile":1337.17,"90th_percentile":1337.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"80","median_amount":13115.46,"10th_percentile":12670.21,"90th_percentile":13193.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":32473.79,"10th_percentile":31147.63,"90th_percentile":34611.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":32927.66,"10th_percentile":32927.66,"90th_percentile":32927.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":38510.02,"10th_percentile":38510.02,"90th_percentile":38510.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":37243.72,"10th_percentile":33865.56,"90th_percentile":39396.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"60","median_amount":30532.94,"10th_percentile":25817.34,"90th_percentile":36503.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9390.84,"10th_percentile":3991.0,"90th_percentile":9646.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"41","median_amount":12975.42,"10th_percentile":10550.74,"90th_percentile":13190.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12983.48,"10th_percentile":10758.61,"90th_percentile":13202.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":37797.68,"10th_percentile":37797.68,"90th_percentile":41817.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Musculoskeletal Procedures","code_information":[{"code":"5116","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4665.38,"10th_percentile":4665.38,"90th_percentile":4665.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18865.97,"10th_percentile":18865.97,"90th_percentile":18865.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":17461.75,"10th_percentile":17461.75,"90th_percentile":17461.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":16442.88,"10th_percentile":15620.74,"90th_percentile":17553.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":38222.59,"10th_percentile":38222.59,"90th_percentile":38222.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18597.16,"10th_percentile":18308.61,"90th_percentile":18799.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"15","median_amount":18701.49,"10th_percentile":18299.84,"90th_percentile":19146.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":38326.91,"10th_percentile":38326.91,"90th_percentile":38326.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":34782.17,"10th_percentile":33989.21,"90th_percentile":35593.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12197.83,"10th_percentile":12197.83,"90th_percentile":12197.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18068.36,"10th_percentile":17542.83,"90th_percentile":18774.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":136.79,"10th_percentile":136.79,"90th_percentile":136.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":46665.56,"10th_percentile":46665.56,"90th_percentile":46665.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Airway Endoscopy","code_information":[{"code":"5151","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":308.8,"10th_percentile":308.8,"90th_percentile":308.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":663.0,"10th_percentile":271.0,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":326.71,"10th_percentile":32.71,"90th_percentile":332.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":293.84,"10th_percentile":293.84,"90th_percentile":293.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":326.71,"10th_percentile":261.37,"90th_percentile":326.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":470.73,"10th_percentile":470.73,"90th_percentile":470.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":460.79,"10th_percentile":460.79,"90th_percentile":465.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"12","median_amount":308.8,"10th_percentile":130.35,"90th_percentile":330.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Airway Endoscopy","code_information":[{"code":"5153","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3435.27,"10th_percentile":3435.27,"90th_percentile":3435.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":3388.0,"90th_percentile":3388.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1744.27,"10th_percentile":1744.27,"90th_percentile":1744.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":1750.27,"10th_percentile":1595.27,"90th_percentile":1751.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":770.93,"10th_percentile":770.93,"90th_percentile":770.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1401.28,"10th_percentile":1386.58,"90th_percentile":3642.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Airway Endoscopy","code_information":[{"code":"5154","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3948.04,"10th_percentile":3948.04,"90th_percentile":3948.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4589.0,"10th_percentile":4589.0,"90th_percentile":4589.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":72.0,"10th_percentile":72.0,"90th_percentile":72.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":18310.2,"10th_percentile":18310.2,"90th_percentile":18310.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7306.33,"10th_percentile":7306.33,"90th_percentile":7306.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3648.04,"10th_percentile":3648.04,"90th_percentile":3648.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3735.27,"10th_percentile":3646.54,"90th_percentile":3736.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7627.51,"10th_percentile":7627.51,"90th_percentile":13751.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8090.93,"10th_percentile":7086.96,"90th_percentile":17510.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":790.72,"10th_percentile":790.72,"90th_percentile":790.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3489.35,"10th_percentile":2994.99,"90th_percentile":6269.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":13235.7,"10th_percentile":13235.7,"90th_percentile":13235.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 Airway Endoscopy","code_information":[{"code":"5155","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":27210.5,"10th_percentile":21215.27,"90th_percentile":27861.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12831.61,"10th_percentile":12024.99,"90th_percentile":16196.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":23143.5,"10th_percentile":23143.5,"90th_percentile":23143.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7007.94,"10th_percentile":7007.94,"90th_percentile":7008.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":27234.98,"10th_percentile":27234.98,"90th_percentile":27234.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":21250.75,"10th_percentile":21250.75,"90th_percentile":21250.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":20646.33,"10th_percentile":20646.33,"90th_percentile":20646.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":19599.67,"10th_percentile":14261.63,"90th_percentile":23649.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7008.95,"10th_percentile":7008.95,"90th_percentile":7008.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 ENT Procedures","code_information":[{"code":"5161","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2287.84,"10th_percentile":2287.84,"90th_percentile":2287.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":746.24,"10th_percentile":746.24,"90th_percentile":746.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.72,"10th_percentile":64.72,"90th_percentile":64.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":67.25,"10th_percentile":67.25,"90th_percentile":67.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3039.56,"10th_percentile":3039.56,"90th_percentile":3039.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2592.37,"10th_percentile":2592.37,"90th_percentile":2592.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":896.14,"10th_percentile":896.14,"90th_percentile":896.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":882.67,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":5636.7,"10th_percentile":4837.2,"90th_percentile":6063.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"35","median_amount":4935.7,"10th_percentile":3218.6,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":5128.5,"10th_percentile":5128.5,"90th_percentile":5128.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":882.67,"10th_percentile":882.67,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":4523.39,"10th_percentile":4523.39,"90th_percentile":4523.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4219.52,"10th_percentile":4219.51,"90th_percentile":4363.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4219.51,"10th_percentile":4219.51,"90th_percentile":4219.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.37,"10th_percentile":1498.37,"90th_percentile":1498.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":871.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":5210.86,"10th_percentile":5210.86,"90th_percentile":5210.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1804.28,"10th_percentile":1804.28,"90th_percentile":1804.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5745.45,"10th_percentile":4409.45,"90th_percentile":6241.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3208.23,"10th_percentile":3005.76,"90th_percentile":3546.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":871.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4051.93,"10th_percentile":3997.0,"90th_percentile":4328.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"77","median_amount":3698.72,"10th_percentile":2748.77,"90th_percentile":4331.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":882.67,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.29,"10th_percentile":1498.29,"90th_percentile":1498.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4603.8,"10th_percentile":4603.8,"90th_percentile":4603.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 ENT Procedures","code_information":[{"code":"5164","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1542.89,"10th_percentile":1542.89,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":7582.62,"10th_percentile":4106.0,"90th_percentile":8378.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"40","median_amount":5082.0,"10th_percentile":3388.0,"90th_percentile":6828.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4549.0,"10th_percentile":4549.0,"90th_percentile":4549.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":10078.46,"10th_percentile":5333.71,"90th_percentile":14231.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1052.77,"10th_percentile":1052.77,"90th_percentile":1334.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6460.19,"10th_percentile":6460.19,"90th_percentile":6460.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"13","median_amount":6476.51,"10th_percentile":6130.51,"90th_percentile":8451.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":6567.79,"10th_percentile":6567.79,"90th_percentile":6567.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":11807.58,"10th_percentile":11807.58,"90th_percentile":11807.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3136.74,"10th_percentile":3136.74,"90th_percentile":3136.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":13693.5,"10th_percentile":7791.0,"90th_percentile":15582.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9157.38,"10th_percentile":6551.29,"90th_percentile":10378.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2091.07,"10th_percentile":2091.07,"90th_percentile":2091.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":9721.46,"10th_percentile":5836.04,"90th_percentile":22593.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"107","median_amount":8293.93,"10th_percentile":4855.86,"90th_percentile":12202.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":893.08,"10th_percentile":824.68,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3285.31,"10th_percentile":3285.31,"90th_percentile":3285.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":6777.19,"10th_percentile":6777.19,"90th_percentile":6777.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 ENT Procedures","code_information":[{"code":"5165","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1334.42,"10th_percentile":1334.42,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5441.0,"10th_percentile":5441.0,"90th_percentile":5441.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4428.0,"10th_percentile":4142.46,"90th_percentile":7816.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":8939.25,"10th_percentile":8939.25,"90th_percentile":8939.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":24426.26,"10th_percentile":24426.26,"90th_percentile":24426.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6048.88,"10th_percentile":4226.0,"90th_percentile":27213.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":824.68,"10th_percentile":824.68,"90th_percentile":824.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":10319.8,"10th_percentile":10319.8,"90th_percentile":10319.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1542.89,"10th_percentile":1542.89,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":9172.74,"10th_percentile":9172.74,"90th_percentile":9172.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"22","median_amount":6841.67,"10th_percentile":6275.51,"90th_percentile":7914.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":893.08,"10th_percentile":893.08,"90th_percentile":893.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":305.43,"10th_percentile":305.43,"90th_percentile":305.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":625.36,"10th_percentile":500.29,"90th_percentile":625.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2815.0,"10th_percentile":2815.0,"90th_percentile":2815.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":4064.7,"10th_percentile":4064.7,"90th_percentile":4064.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1149.93,"10th_percentile":1149.93,"90th_percentile":1149.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":316.96,"10th_percentile":316.96,"90th_percentile":572.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.35,"10th_percentile":1498.35,"90th_percentile":1498.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"91","median_amount":625.36,"10th_percentile":610.96,"90th_percentile":717.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3030.0,"10th_percentile":3030.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1413.26,"10th_percentile":1413.26,"90th_percentile":1413.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":306.26,"10th_percentile":306.26,"90th_percentile":306.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1894.92,"10th_percentile":1330.93,"90th_percentile":3260.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":417.85,"10th_percentile":306.26,"90th_percentile":417.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":610.97,"10th_percentile":488.77,"90th_percentile":888.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":623.18,"10th_percentile":623.18,"90th_percentile":623.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3389.8,"10th_percentile":1563.57,"90th_percentile":21015.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":4135.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1214.57,"10th_percentile":1214.57,"90th_percentile":1214.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3078.41,"10th_percentile":3078.41,"90th_percentile":3078.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1571.27,"10th_percentile":1571.27,"90th_percentile":1709.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":1571.27,"10th_percentile":1296.59,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3030.0,"10th_percentile":3030.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2549.92,"10th_percentile":2549.92,"90th_percentile":2549.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3591.05,"10th_percentile":3046.17,"90th_percentile":5143.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1343.85,"10th_percentile":1343.85,"90th_percentile":1343.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1578.58,"10th_percentile":1439.41,"90th_percentile":4357.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1583.66,"10th_percentile":1583.66,"90th_percentile":1583.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2972.58,"10th_percentile":2805.99,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5602.5,"10th_percentile":5602.5,"90th_percentile":9114.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4222.2,"10th_percentile":4162.2,"90th_percentile":4449.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.73,"10th_percentile":888.73,"90th_percentile":888.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2742.63,"10th_percentile":2742.63,"90th_percentile":2742.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6073.46,"10th_percentile":6073.46,"90th_percentile":6237.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":10226.42,"10th_percentile":10226.42,"90th_percentile":10226.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":21509.71,"10th_percentile":21509.71,"90th_percentile":21509.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3183.63,"10th_percentile":2889.63,"90th_percentile":3191.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1063.78,"10th_percentile":1063.78,"90th_percentile":1063.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"62","median_amount":3183.63,"10th_percentile":2889.63,"90th_percentile":3189.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8405.0,"10th_percentile":8405.0,"90th_percentile":12985.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11810.34,"10th_percentile":8197.93,"90th_percentile":17477.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":10024.89,"10th_percentile":7565.01,"90th_percentile":18597.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":880.46,"10th_percentile":880.46,"90th_percentile":880.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"29","median_amount":2978.09,"10th_percentile":2546.9,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2597.84,"10th_percentile":2529.6,"90th_percentile":2597.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Vascular Procedures","code_information":[{"code":"5184","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5111.28,"10th_percentile":5111.28,"90th_percentile":5111.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10054.28,"10th_percentile":10054.28,"90th_percentile":10054.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5344.5,"10th_percentile":5344.5,"90th_percentile":5405.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5055.4,"10th_percentile":5055.4,"90th_percentile":5055.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5344.5,"10th_percentile":5344.5,"90th_percentile":5344.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Endovascular Procedures","code_information":[{"code":"5191","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1051.33,"10th_percentile":1045.12,"90th_percentile":1579.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":3253.34,"10th_percentile":2602.66,"90th_percentile":3319.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":16297.59,"10th_percentile":12766.14,"90th_percentile":27503.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"20","median_amount":10639.46,"10th_percentile":7290.7,"90th_percentile":18282.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1522.33,"10th_percentile":1522.33,"90th_percentile":1522.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":15872.83,"10th_percentile":15872.83,"90th_percentile":15872.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":13670.15,"10th_percentile":13670.15,"90th_percentile":14554.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3169.11,"10th_percentile":3169.11,"90th_percentile":3169.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"23","median_amount":6373.88,"10th_percentile":6208.88,"90th_percentile":6407.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13422.05,"10th_percentile":13422.05,"90th_percentile":16372.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":3259.34,"10th_percentile":2910.34,"90th_percentile":3343.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1029.77,"10th_percentile":1029.77,"90th_percentile":1029.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":14039.65,"10th_percentile":14039.65,"90th_percentile":14039.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"113","median_amount":3175.11,"10th_percentile":2959.34,"90th_percentile":3260.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":15691.0,"10th_percentile":15691.0,"90th_percentile":17467.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":12156.51,"10th_percentile":12156.51,"90th_percentile":12156.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1481.29,"10th_percentile":1481.29,"90th_percentile":1481.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":13407.62,"10th_percentile":13407.62,"90th_percentile":17618.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":12189.22,"10th_percentile":10359.16,"90th_percentile":23827.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1055.22,"10th_percentile":1055.22,"90th_percentile":1055.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"86","median_amount":3253.34,"10th_percentile":2650.56,"90th_percentile":3261.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3232.5,"10th_percentile":2685.11,"90th_percentile":3318.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":13520.66,"10th_percentile":13520.66,"90th_percentile":13520.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Endovascular Procedures","code_information":[{"code":"5192","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5766.98,"10th_percentile":5472.98,"90th_percentile":11491.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7755.0,"10th_percentile":7755.0,"90th_percentile":7755.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9724.67,"10th_percentile":9724.67,"90th_percentile":9724.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11357.41,"10th_percentile":11357.41,"90th_percentile":22473.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5772.98,"10th_percentile":5766.98,"90th_percentile":6066.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"17","median_amount":5565.77,"10th_percentile":5390.66,"90th_percentile":5772.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":30477.25,"10th_percentile":30477.25,"90th_percentile":30477.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":33614.44,"10th_percentile":33614.44,"90th_percentile":33614.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1586.17,"10th_percentile":1586.17,"90th_percentile":1586.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5775.28,"10th_percentile":5775.28,"90th_percentile":5775.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5558.77,"10th_percentile":4613.59,"90th_percentile":5773.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Endovascular Procedures","code_information":[{"code":"5193","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8288.46,"10th_percentile":8288.46,"90th_percentile":8288.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":10886.6,"10th_percentile":9176.61,"90th_percentile":17053.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":26104.75,"10th_percentile":19340.18,"90th_percentile":29716.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":18462.89,"10th_percentile":13764.07,"90th_percentile":36000.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2690.52,"10th_percentile":2690.52,"90th_percentile":2690.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":16517.79,"10th_percentile":16517.79,"90th_percentile":16517.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22473.33,"10th_percentile":20961.66,"90th_percentile":22473.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":26449.54,"10th_percentile":26449.54,"90th_percentile":26449.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11176.76,"10th_percentile":9063.37,"90th_percentile":11517.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":28224.98,"10th_percentile":28224.98,"90th_percentile":28224.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4698.35,"10th_percentile":4698.35,"90th_percentile":4698.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"60","median_amount":11176.76,"10th_percentile":10416.33,"90th_percentile":11476.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":26201.74,"10th_percentile":18365.0,"90th_percentile":40501.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":25855.45,"10th_percentile":25855.45,"90th_percentile":40726.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":29315.45,"10th_percentile":22507.31,"90th_percentile":37845.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4567.83,"10th_percentile":4567.83,"90th_percentile":4567.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"52","median_amount":11127.77,"10th_percentile":9176.61,"90th_percentile":11479.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14820.9,"10th_percentile":14820.9,"90th_percentile":14820.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Endovascular Procedures","code_information":[{"code":"5194","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17059.78,"10th_percentile":17059.78,"90th_percentile":17059.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":17834.03,"10th_percentile":17834.03,"90th_percentile":17834.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":30197.7,"10th_percentile":30197.7,"90th_percentile":30197.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17053.78,"10th_percentile":17053.78,"90th_percentile":17053.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7365.82,"10th_percentile":7365.82,"90th_percentile":7365.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18162.87,"10th_percentile":17868.87,"90th_percentile":18181.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":55717.31,"10th_percentile":55717.31,"90th_percentile":55717.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6259.67,"10th_percentile":6259.67,"90th_percentile":6259.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18169.87,"10th_percentile":18162.87,"90th_percentile":18170.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Implantation Wireless PA Pressure Monitor","code_information":[{"code":"5200","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28754.69,"10th_percentile":28754.69,"90th_percentile":28754.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28754.69,"10th_percentile":28754.69,"90th_percentile":28754.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7790.71,"10th_percentile":7790.71,"90th_percentile":7790.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28411.69,"10th_percentile":28411.69,"90th_percentile":28411.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Electrophysiologic Procedures","code_information":[{"code":"5212","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2858.05,"10th_percentile":2858.05,"90th_percentile":2858.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":12729.97,"10th_percentile":12729.97,"90th_percentile":12729.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7675.22,"10th_percentile":7675.22,"90th_percentile":7675.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7681.21,"10th_percentile":7681.21,"90th_percentile":7681.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":40790.04,"10th_percentile":40790.04,"90th_percentile":40790.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":18467.99,"10th_percentile":18467.99,"90th_percentile":18467.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7991.22,"10th_percentile":7991.22,"90th_percentile":7991.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5847.78,"10th_percentile":5847.78,"90th_percentile":5847.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Electrophysiologic Procedures","code_information":[{"code":"5213","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":23399.36,"10th_percentile":22804.46,"90th_percentile":24915.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":84776.42,"10th_percentile":65044.25,"90th_percentile":99727.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":51978.28,"10th_percentile":48216.26,"90th_percentile":68285.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7432.76,"10th_percentile":7432.76,"90th_percentile":7432.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":51150.67,"10th_percentile":51150.67,"90th_percentile":51150.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":48615.05,"10th_percentile":48615.05,"90th_percentile":48868.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":70486.1,"10th_percentile":70486.1,"90th_percentile":70486.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24818.71,"10th_percentile":24519.93,"90th_percentile":24819.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10994.46,"10th_percentile":10994.46,"90th_percentile":10994.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"78","median_amount":24819.93,"10th_percentile":23102.96,"90th_percentile":24819.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":43095.74,"10th_percentile":42902.74,"90th_percentile":44069.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":83252.97,"10th_percentile":83252.97,"90th_percentile":83355.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10298.69,"10th_percentile":10298.69,"90th_percentile":10298.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"21","median_amount":65224.12,"10th_percentile":57084.22,"90th_percentile":75676.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8502.31,"10th_percentile":8502.31,"90th_percentile":10952.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":24739.59,"10th_percentile":22755.47,"90th_percentile":24821.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18848.35,"10th_percentile":18848.35,"90th_percentile":18848.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Pacemaker and Similar Procedures","code_information":[{"code":"5221","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3779.14,"10th_percentile":3779.14,"90th_percentile":3779.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pacemaker and Similar Procedures","code_information":[{"code":"5222","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":696.26,"10th_percentile":696.26,"90th_percentile":696.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8076.98,"10th_percentile":8076.98,"90th_percentile":8076.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":16400.31,"10th_percentile":16400.31,"90th_percentile":16400.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8268.48,"10th_percentile":8268.48,"90th_percentile":8268.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1436.35,"10th_percentile":1436.35,"90th_percentile":1436.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8260.14,"10th_percentile":8076.98,"90th_percentile":8376.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":16810.0,"10th_percentile":16810.0,"90th_percentile":16810.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3273.68,"10th_percentile":3273.68,"90th_percentile":3273.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15714.06,"10th_percentile":15714.06,"90th_percentile":15714.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8377.45,"10th_percentile":8268.38,"90th_percentile":10198.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Pacemaker and Similar Procedures","code_information":[{"code":"5223","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":12918.51,"10th_percentile":12918.51,"90th_percentile":12918.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10585.48,"10th_percentile":10585.48,"90th_percentile":10585.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":20346.41,"10th_percentile":20346.41,"90th_percentile":20346.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10591.48,"10th_percentile":9889.73,"90th_percentile":10591.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"34","median_amount":10526.48,"10th_percentile":10164.65,"90th_percentile":10591.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15937.65,"10th_percentile":15937.65,"90th_percentile":15937.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":10592.48,"10th_percentile":10228.52,"90th_percentile":19299.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10797.19,"10th_percentile":10797.19,"90th_percentile":10797.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Pacemaker and Similar Procedures","code_information":[{"code":"5224","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19296.09,"10th_percentile":19296.09,"90th_percentile":19296.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19296.09,"10th_percentile":18996.09,"90th_percentile":19296.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":22760.68,"10th_percentile":22760.68,"90th_percentile":22760.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":38503.86,"10th_percentile":38503.86,"90th_percentile":38503.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7785.82,"10th_percentile":7785.82,"90th_percentile":7785.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 ICD and Similar Procedures","code_information":[{"code":"5231","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":25607.5,"10th_percentile":25607.5,"90th_percentile":25607.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9289.52,"10th_percentile":9289.52,"90th_percentile":9289.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22928.89,"10th_percentile":22928.89,"90th_percentile":22928.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":49024.46,"10th_percentile":49024.46,"90th_percentile":49024.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 ICD and Similar Procedures","code_information":[{"code":"5232","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32429.65,"10th_percentile":32429.65,"90th_percentile":32429.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":25389.85,"10th_percentile":25389.85,"90th_percentile":25389.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":62686.06,"10th_percentile":62686.06,"90th_percentile":62686.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32429.65,"10th_percentile":32429.65,"90th_percentile":32429.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32000.51,"10th_percentile":31996.01,"90th_percentile":32735.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":65506.25,"10th_percentile":55946.83,"90th_percentile":93624.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9301.08,"10th_percentile":9301.08,"90th_percentile":9301.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":89.47,"10th_percentile":89.47,"90th_percentile":89.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":27122.4,"10th_percentile":27122.4,"90th_percentile":27122.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":633.22,"10th_percentile":633.22,"90th_percentile":1266.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2664.67,"10th_percentile":2664.67,"90th_percentile":2664.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1249.51,"10th_percentile":1249.51,"90th_percentile":1249.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2605.73,"10th_percentile":2605.73,"90th_percentile":2605.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":665.37,"10th_percentile":635.02,"90th_percentile":824.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"33","median_amount":802.16,"10th_percentile":633.22,"90th_percentile":1017.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1359.15,"10th_percentile":1343.4,"90th_percentile":2496.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":683.45,"10th_percentile":683.45,"90th_percentile":1088.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":633.23,"10th_percentile":542.56,"90th_percentile":1254.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":351.84,"10th_percentile":310.38,"90th_percentile":424.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"58","median_amount":948.33,"10th_percentile":758.66,"90th_percentile":1168.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"39","median_amount":3335.0,"10th_percentile":1693.02,"90th_percentile":3585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"99","median_amount":2654.0,"10th_percentile":515.45,"90th_percentile":3781.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":445.77,"10th_percentile":343.85,"90th_percentile":870.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3431.21,"10th_percentile":3431.21,"90th_percentile":3938.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":445.78,"10th_percentile":445.78,"90th_percentile":445.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"11","median_amount":5184.38,"10th_percentile":3677.95,"90th_percentile":7925.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":415.64,"10th_percentile":415.64,"90th_percentile":415.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":957.33,"10th_percentile":957.33,"90th_percentile":957.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"59","median_amount":1857.95,"10th_percentile":1727.21,"90th_percentile":2775.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"15","median_amount":2285.01,"10th_percentile":1484.0,"90th_percentile":2965.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4383.76,"10th_percentile":2285.01,"90th_percentile":5342.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"23","median_amount":893.77,"10th_percentile":587.6,"90th_percentile":1350.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":304.59,"10th_percentile":304.59,"90th_percentile":415.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":705.28,"10th_percentile":705.28,"90th_percentile":705.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":4973.14,"10th_percentile":4973.14,"90th_percentile":6284.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":436.42,"10th_percentile":430.12,"90th_percentile":670.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"230","median_amount":948.33,"10th_percentile":881.6,"90th_percentile":1409.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"31","median_amount":4743.5,"10th_percentile":2590.0,"90th_percentile":6478.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4214.56,"10th_percentile":854.18,"90th_percentile":6954.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":360.96,"10th_percentile":304.59,"90th_percentile":692.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4686.89,"10th_percentile":3676.27,"90th_percentile":4692.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"224","median_amount":3788.67,"10th_percentile":1837.88,"90th_percentile":7048.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"75","median_amount":400.73,"10th_percentile":304.59,"90th_percentile":784.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":955.83,"10th_percentile":955.83,"90th_percentile":955.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.6,"10th_percentile":888.6,"90th_percentile":888.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"108","median_amount":895.36,"10th_percentile":590.63,"90th_percentile":1319.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"18","median_amount":903.17,"10th_percentile":773.83,"90th_percentile":1450.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":882.21,"10th_percentile":882.21,"90th_percentile":882.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":9428.42,"10th_percentile":4741.92,"90th_percentile":11758.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":801.46,"10th_percentile":801.46,"90th_percentile":801.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1926.57,"10th_percentile":1859.58,"90th_percentile":3407.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3759.23,"10th_percentile":3625.63,"90th_percentile":3778.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2965.62,"10th_percentile":2152.49,"90th_percentile":4043.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1931.43,"10th_percentile":1931.43,"90th_percentile":1931.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1850.58,"10th_percentile":1624.77,"90th_percentile":2033.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1244.32,"10th_percentile":801.46,"90th_percentile":1659.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2475.57,"10th_percentile":2475.57,"90th_percentile":2475.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2159.97,"10th_percentile":2159.97,"90th_percentile":2159.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":872.84,"10th_percentile":483.16,"90th_percentile":872.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"124","median_amount":1918.77,"10th_percentile":1535.01,"90th_percentile":1924.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"13","median_amount":6934.5,"10th_percentile":4761.0,"90th_percentile":8090.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7321.02,"10th_percentile":6356.76,"90th_percentile":8644.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":801.46,"10th_percentile":801.46,"90th_percentile":801.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2940.26,"10th_percentile":2940.26,"90th_percentile":2940.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"84","median_amount":4491.55,"10th_percentile":3416.86,"90th_percentile":8940.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":831.28,"10th_percentile":415.64,"90th_percentile":1244.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1856.49,"10th_percentile":1856.49,"90th_percentile":1856.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"72","median_amount":1799.47,"10th_percentile":1480.47,"90th_percentile":2114.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1510.08,"10th_percentile":1461.91,"90th_percentile":1565.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Upper GI Procedures","code_information":[{"code":"5303","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3554.21,"10th_percentile":3554.21,"90th_percentile":3554.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3848.21,"10th_percentile":3848.21,"90th_percentile":3854.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3854.21,"10th_percentile":3554.21,"90th_percentile":3855.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1114.17,"10th_percentile":1114.17,"90th_percentile":1114.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":13391.44,"10th_percentile":13391.44,"90th_percentile":13391.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3593.11,"10th_percentile":3593.11,"90th_percentile":3593.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":421.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":922.18,"10th_percentile":861.04,"90th_percentile":1883.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"34","median_amount":3335.0,"10th_percentile":3174.0,"90th_percentile":3504.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":443.04,"10th_percentile":433.69,"90th_percentile":859.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4547.8,"10th_percentile":4547.8,"90th_percentile":4547.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":3743.17,"10th_percentile":3743.17,"90th_percentile":3743.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":413.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":5132.3,"10th_percentile":4098.71,"90th_percentile":5344.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":888.87,"10th_percentile":870.04,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"41","median_amount":1806.72,"10th_percentile":1695.72,"90th_percentile":1816.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"30","median_amount":1543.0,"10th_percentile":1492.0,"90th_percentile":2209.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4633.84,"10th_percentile":4633.84,"90th_percentile":4633.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":922.18,"10th_percentile":888.87,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":711.1,"10th_percentile":711.1,"90th_percentile":711.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":5527.1,"10th_percentile":5302.65,"90th_percentile":6362.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":433.69,"10th_percentile":433.69,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"186","median_amount":922.18,"10th_percentile":861.04,"90th_percentile":1031.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"42","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":4761.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"22","median_amount":4479.92,"10th_percentile":4095.1,"90th_percentile":5388.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":418.38,"10th_percentile":418.38,"90th_percentile":418.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4646.23,"10th_percentile":4192.63,"90th_percentile":6637.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"258","median_amount":4200.18,"10th_percentile":3683.12,"90th_percentile":4623.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":413.04,"10th_percentile":409.48,"90th_percentile":819.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"96","median_amount":922.18,"10th_percentile":888.87,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":940.62,"10th_percentile":879.46,"90th_percentile":1266.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4395.36,"10th_percentile":4395.36,"90th_percentile":4395.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":409.98,"10th_percentile":409.48,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"47","median_amount":1192.61,"10th_percentile":1113.55,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"73","median_amount":4106.0,"10th_percentile":4041.48,"90th_percentile":5773.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"192","median_amount":3388.0,"10th_percentile":3388.0,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":867.38,"10th_percentile":433.69,"90th_percentile":870.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4287.66,"10th_percentile":3331.15,"90th_percentile":4746.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1228.59,"10th_percentile":1228.59,"90th_percentile":1228.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"14","median_amount":5953.83,"10th_percentile":5421.47,"90th_percentile":7506.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":837.58,"10th_percentile":837.58,"90th_percentile":1241.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1192.61,"10th_percentile":1147.68,"90th_percentile":2238.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"66","median_amount":2336.56,"10th_percentile":2193.02,"90th_percentile":3289.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"41","median_amount":1543.0,"10th_percentile":1492.0,"90th_percentile":3197.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"13","median_amount":2908.91,"10th_percentile":1543.0,"90th_percentile":5953.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"56","median_amount":1192.61,"10th_percentile":1113.55,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":826.08,"10th_percentile":413.04,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":918.14,"10th_percentile":918.14,"90th_percentile":1315.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":422.29,"10th_percentile":422.29,"90th_percentile":422.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"15","median_amount":5943.84,"10th_percentile":5521.45,"90th_percentile":7040.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":867.38,"10th_percentile":443.04,"90th_percentile":1348.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"341","median_amount":1192.61,"10th_percentile":1147.68,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"61","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"19","median_amount":5408.25,"10th_percentile":4681.27,"90th_percentile":8002.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":826.08,"10th_percentile":810.21,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4864.29,"10th_percentile":4251.66,"90th_percentile":6496.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"423","median_amount":4834.43,"10th_percentile":4287.39,"90th_percentile":7630.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":837.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"207","median_amount":1192.62,"10th_percentile":1147.68,"90th_percentile":1788.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"16","median_amount":1218.29,"10th_percentile":1135.83,"90th_percentile":1755.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5116.64,"10th_percentile":5116.64,"90th_percentile":5116.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2779.87,"10th_percentile":2779.87,"90th_percentile":2779.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4314.0,"10th_percentile":4314.0,"90th_percentile":4314.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2116.78,"10th_percentile":2116.78,"90th_percentile":2116.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5349.96,"10th_percentile":5349.96,"90th_percentile":5434.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1161.49,"10th_percentile":1161.49,"90th_percentile":1161.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2773.87,"10th_percentile":2773.87,"90th_percentile":2773.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":6903.45,"10th_percentile":6903.45,"90th_percentile":6903.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5684.78,"10th_percentile":5684.78,"90th_percentile":5684.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":8934.35,"10th_percentile":8934.35,"90th_percentile":8934.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":7803.61,"10th_percentile":4508.76,"90th_percentile":10815.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2594.99,"10th_percentile":2210.92,"90th_percentile":2738.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex GI Procedures","code_information":[{"code":"5331","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5727.15,"10th_percentile":5727.15,"90th_percentile":5727.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5613.28,"10th_percentile":5613.28,"90th_percentile":5613.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9593.54,"10th_percentile":9593.54,"90th_percentile":9593.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1559.21,"10th_percentile":1559.21,"90th_percentile":1559.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11796.54,"10th_percentile":11796.54,"90th_percentile":11796.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6027.15,"10th_percentile":6027.15,"90th_percentile":6027.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5542.79,"10th_percentile":5542.79,"90th_percentile":5542.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":19229.93,"10th_percentile":14391.51,"90th_percentile":20349.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5663.45,"10th_percentile":5663.45,"90th_percentile":6028.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7352.88,"10th_percentile":7352.88,"90th_percentile":7352.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":4186.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":15908.73,"10th_percentile":15908.73,"90th_percentile":15908.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7029.87,"10th_percentile":7029.87,"90th_percentile":7029.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12786.93,"10th_percentile":12786.93,"90th_percentile":14131.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":18463.76,"10th_percentile":18463.76,"90th_percentile":18463.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3338.94,"10th_percentile":3332.94,"90th_percentile":3364.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1928.43,"10th_percentile":1928.43,"90th_percentile":1928.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3369.2,"10th_percentile":3275.57,"90th_percentile":3902.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8657.0,"10th_percentile":8657.0,"90th_percentile":8657.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":41706.01,"10th_percentile":41706.01,"90th_percentile":41706.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":9807.81,"10th_percentile":6655.5,"90th_percentile":21178.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3569.58,"10th_percentile":3175.18,"90th_percentile":3577.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5342","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4716.75,"10th_percentile":4716.75,"90th_percentile":4716.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3313.03,"10th_percentile":3313.03,"90th_percentile":3313.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1928.43,"10th_percentile":1928.43,"90th_percentile":1928.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1937.78,"10th_percentile":1937.78,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":28405.93,"10th_percentile":28405.93,"90th_percentile":28405.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6687.82,"10th_percentile":6687.82,"90th_percentile":6687.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1937.78,"10th_percentile":1937.78,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6319.75,"10th_percentile":6319.75,"90th_percentile":6319.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":20217.27,"10th_percentile":20217.27,"90th_percentile":20217.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2099.25,"10th_percentile":2099.25,"90th_percentile":2099.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6318.69,"10th_percentile":6318.69,"90th_percentile":6318.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":29317.4,"10th_percentile":29317.4,"90th_percentile":29317.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1934.9,"10th_percentile":1513.22,"90th_percentile":2108.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5781.84,"10th_percentile":4722.05,"90th_percentile":5907.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"28","median_amount":6546.36,"10th_percentile":5822.74,"90th_percentile":9693.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"51","median_amount":5257.03,"10th_percentile":4610.42,"90th_percentile":8422.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4617.05,"10th_percentile":4617.05,"90th_percentile":4617.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":25897.42,"10th_percentile":25897.42,"90th_percentile":25897.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":17100.67,"10th_percentile":17100.67,"90th_percentile":17100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":13539.7,"10th_percentile":13539.7,"90th_percentile":13539.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1815.49,"10th_percentile":1815.49,"90th_percentile":1815.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"15","median_amount":11561.82,"10th_percentile":10994.15,"90th_percentile":11564.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13350.96,"10th_percentile":7926.0,"90th_percentile":21704.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":16747.98,"10th_percentile":16747.98,"90th_percentile":18048.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5903.84,"10th_percentile":5614.3,"90th_percentile":5908.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1832.16,"10th_percentile":1832.16,"90th_percentile":1832.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":20501.38,"10th_percentile":20501.38,"90th_percentile":20501.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1161.49,"10th_percentile":1152.14,"90th_percentile":2177.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"64","median_amount":5907.34,"10th_percentile":5516.12,"90th_percentile":6034.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":17314.0,"10th_percentile":16810.0,"90th_percentile":24950.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":22327.08,"10th_percentile":18405.29,"90th_percentile":24321.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1554.0,"10th_percentile":1554.0,"90th_percentile":1554.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":25222.19,"10th_percentile":25222.19,"90th_percentile":29289.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"113","median_amount":16624.91,"10th_percentile":11120.42,"90th_percentile":21122.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":1824.84,"10th_percentile":1513.22,"90th_percentile":2658.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"17","median_amount":5866.23,"10th_percentile":4721.61,"90th_percentile":5993.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4816.13,"10th_percentile":4816.13,"90th_percentile":4816.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":25321.15,"10th_percentile":25321.15,"90th_percentile":25321.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":16626.55,"10th_percentile":16626.55,"90th_percentile":16626.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2917.59,"10th_percentile":2917.59,"90th_percentile":2917.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10011.15,"10th_percentile":10011.15,"90th_percentile":10011.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":9563.81,"10th_percentile":9356.0,"90th_percentile":14034.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":7808.5,"10th_percentile":7609.0,"90th_percentile":12417.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2097.63,"10th_percentile":2097.63,"90th_percentile":2097.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":27299.49,"10th_percentile":27299.49,"90th_percentile":37851.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3.0,"10th_percentile":3.0,"90th_percentile":3.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":20632.99,"10th_percentile":20632.63,"90th_percentile":20638.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":25217.73,"10th_percentile":22462.03,"90th_percentile":37211.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":20917.18,"10th_percentile":20917.18,"90th_percentile":20917.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10538.73,"10th_percentile":10538.73,"90th_percentile":10540.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2445.15,"10th_percentile":2445.15,"90th_percentile":2451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":23204.78,"10th_percentile":23204.78,"90th_percentile":23204.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"15","median_amount":10537.64,"10th_percentile":10536.72,"90th_percentile":10540.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":20592.0,"10th_percentile":17314.0,"90th_percentile":36787.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":25181.44,"10th_percentile":18732.36,"90th_percentile":31245.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":23779.18,"10th_percentile":23779.18,"90th_percentile":23779.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":25752.42,"10th_percentile":20261.1,"90th_percentile":40525.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2504.46,"10th_percentile":2430.25,"90th_percentile":3351.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"11","median_amount":10538.95,"10th_percentile":8425.14,"90th_percentile":10540.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8169.1,"10th_percentile":0.8,"90th_percentile":8594.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":21853.62,"10th_percentile":21853.62,"90th_percentile":21853.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":146.87,"10th_percentile":146.87,"90th_percentile":146.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1985.41,"10th_percentile":1985.41,"90th_percentile":1985.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":381.75,"10th_percentile":381.75,"90th_percentile":381.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Urology and Related Services","code_information":[{"code":"5372","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":675.13,"10th_percentile":675.13,"90th_percentile":675.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1322.71,"10th_percentile":1322.71,"90th_percentile":1322.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":681.13,"10th_percentile":681.13,"90th_percentile":681.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":675.13,"10th_percentile":675.13,"90th_percentile":675.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":522.58,"10th_percentile":522.58,"90th_percentile":522.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":707.36,"10th_percentile":707.36,"90th_percentile":707.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2072.02,"10th_percentile":1980.9,"90th_percentile":3488.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6159.0,"10th_percentile":6159.0,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":2973.38,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":709.83,"10th_percentile":709.83,"90th_percentile":709.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2081.02,"10th_percentile":2081.02,"90th_percentile":2081.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"11","median_amount":3880.95,"10th_percentile":3880.95,"90th_percentile":4083.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":10083.85,"10th_percentile":10083.85,"90th_percentile":10083.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1980.9,"10th_percentile":1657.62,"90th_percentile":2080.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"68","median_amount":2074.52,"10th_percentile":1778.02,"90th_percentile":2078.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7791.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":10514.15,"10th_percentile":10514.15,"90th_percentile":10514.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":8630.81,"10th_percentile":4778.49,"90th_percentile":11000.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1987.91,"10th_percentile":1665.33,"90th_percentile":2080.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1527.31,"10th_percentile":1527.31,"90th_percentile":1527.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Urology and Related Services","code_information":[{"code":"5374","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1166.97,"10th_percentile":1166.97,"90th_percentile":1166.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"16","median_amount":3488.56,"10th_percentile":3390.46,"90th_percentile":4559.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6642.0,"10th_percentile":4821.0,"90th_percentile":8392.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"19","median_amount":4246.1,"10th_percentile":3734.97,"90th_percentile":5602.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":7587.45,"10th_percentile":7587.45,"90th_percentile":7587.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":18658.37,"10th_percentile":18658.37,"90th_percentile":18658.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6642.53,"10th_percentile":6642.53,"90th_percentile":6854.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":15892.65,"10th_percentile":13063.6,"90th_percentile":21360.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3390.46,"10th_percentile":3220.04,"90th_percentile":3494.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":650.37,"10th_percentile":650.37,"90th_percentile":650.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1164.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"80","median_amount":3397.46,"10th_percentile":3194.56,"90th_percentile":3494.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":18822.3,"10th_percentile":18822.3,"90th_percentile":18822.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":13747.27,"10th_percentile":13747.27,"90th_percentile":13747.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1141.29,"10th_percentile":1141.29,"90th_percentile":1141.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"32","median_amount":9280.99,"10th_percentile":7618.37,"90th_percentile":16003.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":979.34,"10th_percentile":649.28,"90th_percentile":1715.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"47","median_amount":3416.85,"10th_percentile":3081.87,"90th_percentile":3496.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2766.61,"10th_percentile":2766.61,"90th_percentile":3558.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1768.62,"10th_percentile":1768.62,"90th_percentile":1768.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":5141.98,"10th_percentile":4847.98,"90th_percentile":5716.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5982.2,"10th_percentile":4457.28,"90th_percentile":9788.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"22","median_amount":4574.13,"10th_percentile":3985.2,"90th_percentile":6003.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":15014.38,"10th_percentile":15014.38,"90th_percentile":15014.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":19060.75,"10th_percentile":19060.75,"90th_percentile":23644.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2530.27,"10th_percentile":2530.27,"90th_percentile":2530.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"11","median_amount":10074.09,"10th_percentile":9859.24,"90th_percentile":10076.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":19798.02,"10th_percentile":18450.18,"90th_percentile":20263.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"13","median_amount":5141.98,"10th_percentile":4738.32,"90th_percentile":5661.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1733.64,"10th_percentile":1733.64,"90th_percentile":1733.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3840.87,"10th_percentile":3840.87,"90th_percentile":3840.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7482.65,"10th_percentile":7482.65,"90th_percentile":7482.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":46877.92,"10th_percentile":46877.92,"90th_percentile":46877.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"73","median_amount":5147.98,"10th_percentile":4847.98,"90th_percentile":5923.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":15234.0,"10th_percentile":14864.73,"90th_percentile":15691.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":16645.19,"10th_percentile":14869.92,"90th_percentile":18283.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1772.64,"10th_percentile":1772.64,"90th_percentile":1772.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":14208.49,"10th_percentile":14208.49,"90th_percentile":14208.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"52","median_amount":15914.3,"10th_percentile":12286.42,"90th_percentile":22029.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":1746.97,"10th_percentile":1539.83,"90th_percentile":1891.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5032.32,"10th_percentile":5032.32,"90th_percentile":5032.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"38","median_amount":5038.22,"10th_percentile":4689.32,"90th_percentile":5609.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4106.38,"10th_percentile":4106.38,"90th_percentile":4106.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Urology and Related Services","code_information":[{"code":"5376","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":17036.36,"10th_percentile":17036.36,"90th_percentile":17036.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9011.11,"10th_percentile":9011.11,"90th_percentile":9011.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"61","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":184.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":820.98,"10th_percentile":578.99,"90th_percentile":1484.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"61","median_amount":425.83,"10th_percentile":339.88,"90th_percentile":565.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"42","median_amount":85.81,"10th_percentile":84.44,"90th_percentile":235.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"18","median_amount":1063.13,"10th_percentile":588.0,"90th_percentile":1365.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":85.81,"10th_percentile":80.42,"90th_percentile":120.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":898.66,"10th_percentile":606.05,"90th_percentile":1210.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":250.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":654.03,"10th_percentile":398.65,"90th_percentile":658.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":966.42,"10th_percentile":530.45,"90th_percentile":1510.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":999.9,"10th_percentile":999.9,"90th_percentile":999.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":172.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":267.06,"10th_percentile":267.06,"90th_percentile":267.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1169.1,"10th_percentile":1169.1,"90th_percentile":1800.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":105.7,"10th_percentile":85.81,"90th_percentile":235.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"25","median_amount":913.28,"10th_percentile":503.38,"90th_percentile":1428.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":954.24,"10th_percentile":490.69,"90th_percentile":1706.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":81.72,"10th_percentile":80.42,"90th_percentile":233.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":481.28,"10th_percentile":439.5,"90th_percentile":1057.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"167","median_amount":500.53,"10th_percentile":396.43,"90th_percentile":902.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"101","median_amount":81.72,"10th_percentile":80.42,"90th_percentile":206.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.28,"10th_percentile":155.04,"90th_percentile":267.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":317.93,"10th_percentile":193.79,"90th_percentile":340.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Gynecologic Procedures","code_information":[{"code":"5412","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":591.68,"10th_percentile":591.68,"90th_percentile":591.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1096.95,"10th_percentile":1096.95,"90th_percentile":1096.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Gynecologic Procedures","code_information":[{"code":"5413","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6363.25,"10th_percentile":6363.25,"90th_percentile":6363.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":988.74,"10th_percentile":920.81,"90th_percentile":995.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3222.04,"10th_percentile":3222.04,"90th_percentile":3222.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3451.26,"10th_percentile":3284.8,"90th_percentile":4106.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"14","median_amount":3388.0,"10th_percentile":2786.27,"90th_percentile":3786.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":7262.62,"10th_percentile":7262.62,"90th_percentile":7262.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6301.97,"10th_percentile":5956.97,"90th_percentile":6336.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3824.0,"10th_percentile":3823.99,"90th_percentile":8375.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2361.96,"10th_percentile":2361.96,"90th_percentile":2361.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":124.18,"10th_percentile":124.18,"90th_percentile":124.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3222.04,"10th_percentile":2922.04,"90th_percentile":3223.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7791.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7491.87,"10th_percentile":7491.87,"90th_percentile":8251.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":8811.02,"10th_percentile":4729.63,"90th_percentile":11502.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":989.87,"10th_percentile":742.85,"90th_percentile":2309.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3216.04,"10th_percentile":2858.34,"90th_percentile":3417.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2481.08,"10th_percentile":2481.08,"90th_percentile":2481.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":15913.78,"10th_percentile":15913.78,"90th_percentile":15913.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 Gynecologic Procedures","code_information":[{"code":"5415","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4999.12,"10th_percentile":4999.12,"90th_percentile":4999.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":13039.51,"10th_percentile":13039.51,"90th_percentile":13039.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4428.0,"10th_percentile":3757.6,"90th_percentile":6642.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9782.44,"10th_percentile":9782.44,"90th_percentile":9782.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13133.19,"10th_percentile":13133.19,"90th_percentile":13133.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":15163.48,"10th_percentile":15163.48,"90th_percentile":15163.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4999.12,"10th_percentile":4699.12,"90th_percentile":4999.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":14962.74,"10th_percentile":8405.0,"90th_percentile":17115.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9017.35,"10th_percentile":9017.35,"90th_percentile":9017.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5854.66,"10th_percentile":5854.66,"90th_percentile":5854.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"28","median_amount":9956.85,"10th_percentile":8393.34,"90th_percentile":12198.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1952.97,"10th_percentile":1952.97,"90th_percentile":1952.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4993.82,"10th_percentile":4844.38,"90th_percentile":5000.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Gynecologic Procedures","code_information":[{"code":"5416","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7479.7,"10th_percentile":7479.7,"90th_percentile":7479.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":15872.11,"10th_percentile":15872.11,"90th_percentile":15872.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7356.11,"10th_percentile":7356.11,"90th_percentile":7356.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7479.71,"10th_percentile":7479.71,"90th_percentile":7480.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5700.03,"10th_percentile":5700.03,"90th_percentile":5700.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":563.23,"10th_percentile":559.46,"90th_percentile":563.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":1705.69,"10th_percentile":1475.39,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"19","median_amount":4106.0,"10th_percentile":2470.14,"90th_percentile":14339.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"46","median_amount":3388.0,"10th_percentile":2938.36,"90th_percentile":9962.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":10489.5,"10th_percentile":10489.5,"90th_percentile":10489.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":591.4,"10th_percentile":591.4,"90th_percentile":591.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":6357.07,"10th_percentile":5852.6,"90th_percentile":8452.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":844.84,"10th_percentile":844.84,"90th_percentile":844.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"12","median_amount":3678.91,"10th_percentile":3678.91,"90th_percentile":3871.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"11","median_amount":3170.0,"10th_percentile":3170.0,"90th_percentile":7361.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":7268.09,"10th_percentile":7268.09,"90th_percentile":7268.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1877.78,"10th_percentile":1583.19,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":7558.21,"10th_percentile":7558.21,"90th_percentile":7558.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"119","median_amount":1882.28,"10th_percentile":1681.19,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"18","median_amount":7791.21,"10th_percentile":7564.0,"90th_percentile":12479.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7109.56,"10th_percentile":5829.88,"90th_percentile":12604.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":563.23,"10th_percentile":563.23,"90th_percentile":563.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7467.34,"10th_percentile":7467.34,"90th_percentile":7467.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"101","median_amount":6860.07,"10th_percentile":5433.77,"90th_percentile":12251.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":563.23,"10th_percentile":563.23,"90th_percentile":1188.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"77","median_amount":1885.68,"10th_percentile":1580.15,"90th_percentile":1983.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1611.76,"10th_percentile":1611.76,"90th_percentile":1611.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":8835.35,"10th_percentile":6517.56,"90th_percentile":12275.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":7167.15,"10th_percentile":7167.15,"90th_percentile":7167.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":304.08,"10th_percentile":238.87,"90th_percentile":1687.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":2013.96,"10th_percentile":1344.18,"90th_percentile":3335.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":2411.25,"10th_percentile":1282.52,"90th_percentile":3981.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1445.25,"10th_percentile":1445.25,"90th_percentile":1445.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":334.5,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":3374.71,"10th_percentile":3374.71,"90th_percentile":3374.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":304.67,"10th_percentile":304.67,"90th_percentile":304.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"16","median_amount":588.01,"10th_percentile":564.35,"90th_percentile":3353.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2662.09,"10th_percentile":1781.08,"90th_percentile":3007.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":304.58,"10th_percentile":185.0,"90th_percentile":1277.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":235.14,"10th_percentile":235.14,"90th_percentile":235.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1936.84,"10th_percentile":1936.84,"90th_percentile":3669.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"107","median_amount":298.58,"10th_percentile":278.78,"90th_percentile":853.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2039.25,"10th_percentile":1457.25,"90th_percentile":2505.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2806.1,"10th_percentile":2775.29,"90th_percentile":3083.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":1574.16,"10th_percentile":958.2,"90th_percentile":3270.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":221.54,"10th_percentile":221.54,"90th_percentile":221.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"60","median_amount":304.67,"10th_percentile":238.87,"90th_percentile":1549.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":304.54,"10th_percentile":304.54,"90th_percentile":304.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2133.46,"10th_percentile":2133.46,"90th_percentile":2186.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":845.64,"10th_percentile":845.64,"90th_percentile":845.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.65,"10th_percentile":184.56,"90th_percentile":406.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"35","median_amount":560.38,"10th_percentile":406.47,"90th_percentile":700.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"28","median_amount":3335.0,"10th_percentile":2644.25,"90th_percentile":5002.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"46","median_amount":2654.0,"10th_percentile":2581.66,"90th_percentile":2815.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":334.5,"10th_percentile":223.01,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2537.65,"10th_percentile":2537.65,"90th_percentile":2755.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":3155.84,"10th_percentile":3155.84,"90th_percentile":5636.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.41,"10th_percentile":315.65,"90th_percentile":326.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":259.47,"10th_percentile":259.47,"90th_percentile":709.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"32","median_amount":1372.36,"10th_percentile":1317.68,"90th_percentile":1837.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2865.78,"10th_percentile":2546.81,"90th_percentile":5678.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2865.78,"10th_percentile":2865.78,"90th_percentile":2865.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":678.56,"10th_percentile":406.47,"90th_percentile":706.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":324.71,"10th_percentile":315.65,"90th_percentile":324.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":3351.39,"10th_percentile":3187.03,"90th_percentile":6175.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1200.0,"10th_percentile":1200.0,"90th_percentile":1200.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":232.52,"10th_percentile":223.01,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"232","median_amount":700.47,"10th_percentile":654.03,"90th_percentile":706.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"18","median_amount":3030.0,"10th_percentile":2942.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"12","median_amount":2627.89,"10th_percentile":2474.0,"90th_percentile":2734.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":276.84,"10th_percentile":276.84,"90th_percentile":276.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2665.22,"10th_percentile":2454.98,"90th_percentile":4930.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"174","median_amount":2501.84,"10th_percentile":1992.89,"90th_percentile":3815.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":315.65,"10th_percentile":190.65,"90th_percentile":555.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"159","median_amount":678.47,"10th_percentile":357.48,"90th_percentile":707.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":571.59,"10th_percentile":571.59,"90th_percentile":686.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":3242.7,"10th_percentile":2943.0,"90th_percentile":4613.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":946.94,"10th_percentile":946.94,"90th_percentile":946.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"22","median_amount":1256.77,"10th_percentile":906.51,"90th_percentile":1350.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":3504.0,"10th_percentile":3185.0,"90th_percentile":13568.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"37","median_amount":5816.61,"10th_percentile":2423.2,"90th_percentile":11585.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4222.5,"10th_percentile":4222.5,"90th_percentile":4222.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2576.05,"10th_percentile":2576.05,"90th_percentile":2576.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":16273.59,"10th_percentile":16273.59,"90th_percentile":16273.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.65,"10th_percentile":315.65,"90th_percentile":315.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":893.46,"10th_percentile":459.51,"90th_percentile":1358.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"36","median_amount":2646.39,"10th_percentile":1665.08,"90th_percentile":2901.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2399.99,"10th_percentile":1221.0,"90th_percentile":2556.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3343.9,"10th_percentile":3343.9,"90th_percentile":11659.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"31","median_amount":1054.58,"10th_percentile":676.45,"90th_percentile":1357.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":789.12,"10th_percentile":317.41,"90th_percentile":789.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":13439.29,"10th_percentile":9938.6,"90th_percentile":14380.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"206","median_amount":1019.97,"10th_percentile":886.46,"90th_percentile":1350.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":4075.0,"10th_percentile":2942.0,"90th_percentile":5712.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5841.35,"10th_percentile":3346.77,"90th_percentile":8865.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"107","median_amount":6170.85,"10th_percentile":2977.09,"90th_percentile":11705.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":789.12,"10th_percentile":315.65,"90th_percentile":1110.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":597.36,"10th_percentile":597.36,"90th_percentile":597.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"143","median_amount":908.42,"10th_percentile":672.65,"90th_percentile":1357.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":1102.24,"10th_percentile":1080.62,"90th_percentile":1102.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":8092.66,"10th_percentile":3365.1,"90th_percentile":11757.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Neurostimulator and Related Procedures","code_information":[{"code":"5461","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2953.89,"10th_percentile":2953.89,"90th_percentile":2953.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1319.63,"10th_percentile":1319.63,"90th_percentile":1319.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Neurostimulator and Related Procedures","code_information":[{"code":"5464","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":21696.58,"10th_percentile":21696.58,"90th_percentile":21696.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":31106.69,"10th_percentile":31106.69,"90th_percentile":31106.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9304.99,"10th_percentile":9304.99,"90th_percentile":9304.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22062.88,"10th_percentile":22062.88,"90th_percentile":22062.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Neurostimulator and Related Procedures","code_information":[{"code":"5465","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":30578.2,"10th_percentile":30578.2,"90th_percentile":30578.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":60388.77,"10th_percentile":60388.77,"90th_percentile":60388.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Intraocular Procedures","code_information":[{"code":"5491","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":709.18,"10th_percentile":709.18,"90th_percentile":714.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"55","median_amount":2197.94,"10th_percentile":1814.64,"90th_percentile":2312.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4106.0,"10th_percentile":3284.8,"90th_percentile":4523.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":3588.64,"10th_percentile":3229.4,"90th_percentile":3794.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3219.12,"10th_percentile":3219.12,"90th_percentile":3219.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1712.98,"10th_percentile":1712.98,"90th_percentile":2471.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4242.02,"10th_percentile":4242.02,"90th_percentile":4519.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4384.28,"10th_percentile":519.0,"90th_percentile":4519.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"87","median_amount":2272.39,"10th_percentile":1963.91,"90th_percentile":2482.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":8107.14,"10th_percentile":7266.97,"90th_percentile":8779.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"388","median_amount":2306.91,"10th_percentile":2012.91,"90th_percentile":2541.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7564.0,"10th_percentile":7564.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6917.15,"10th_percentile":6593.01,"90th_percentile":7381.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7161.15,"10th_percentile":7161.15,"90th_percentile":7161.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":5896.02,"10th_percentile":4665.31,"90th_percentile":6949.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":714.93,"10th_percentile":714.93,"90th_percentile":1429.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2274.29,"10th_percentile":2274.29,"90th_percentile":2274.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"205","median_amount":2274.29,"10th_percentile":1845.53,"90th_percentile":2316.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":2108.05,"10th_percentile":1882.44,"90th_percentile":2362.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":6954.26,"10th_percentile":6954.26,"90th_percentile":7539.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Intraocular Procedures","code_information":[{"code":"5492","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3775.04,"10th_percentile":3775.04,"90th_percentile":3775.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","code_information":[{"code":"5503","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2359.74,"10th_percentile":2359.74,"90th_percentile":2359.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8470.0,"10th_percentile":8470.0,"90th_percentile":8470.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1978.65,"10th_percentile":1978.65,"90th_percentile":1978.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":111.49,"10th_percentile":111.49,"90th_percentile":111.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2303.58,"10th_percentile":2278.65,"90th_percentile":2365.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2279.65,"10th_percentile":2213.21,"90th_percentile":2367.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1925.54,"10th_percentile":1925.54,"90th_percentile":1925.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1967.25,"10th_percentile":1967.25,"90th_percentile":1967.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"60","median_amount":23.0,"10th_percentile":23.0,"90th_percentile":263.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"184","median_amount":89.06,"10th_percentile":71.25,"90th_percentile":168.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"172","median_amount":70.88,"10th_percentile":55.89,"90th_percentile":718.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"371","median_amount":67.33,"10th_percentile":53.99,"90th_percentile":776.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":24.5,"10th_percentile":24.15,"90th_percentile":218.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":456.29,"10th_percentile":456.29,"90th_percentile":456.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"15","median_amount":456.0,"10th_percentile":361.0,"90th_percentile":708.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":24.16,"10th_percentile":23.33,"90th_percentile":241.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"42","median_amount":427.55,"10th_percentile":403.75,"90th_percentile":970.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"24","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":171.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":83.75,"10th_percentile":58.98,"90th_percentile":89.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"58","median_amount":175.4,"10th_percentile":173.15,"90th_percentile":402.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"131","median_amount":353.39,"10th_percentile":353.39,"90th_percentile":706.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"14","median_amount":353.39,"10th_percentile":339.88,"90th_percentile":706.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"142","median_amount":90.88,"10th_percentile":84.85,"90th_percentile":204.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"33","median_amount":34.5,"10th_percentile":23.0,"90th_percentile":208.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":70.7,"10th_percentile":70.7,"90th_percentile":70.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":36.09,"10th_percentile":36.09,"90th_percentile":36.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":89.43,"10th_percentile":71.25,"90th_percentile":707.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"25","median_amount":413.25,"10th_percentile":330.6,"90th_percentile":1033.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"81","median_amount":24.15,"10th_percentile":24.15,"90th_percentile":101.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1019","median_amount":89.66,"10th_percentile":49.86,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"172","median_amount":475.0,"10th_percentile":440.0,"90th_percentile":816.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"51","median_amount":399.08,"10th_percentile":177.11,"90th_percentile":895.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":23.0,"10th_percentile":23.0,"90th_percentile":46.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":356.25,"10th_percentile":356.25,"90th_percentile":356.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"33","median_amount":356.25,"10th_percentile":285.0,"90th_percentile":712.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"938","median_amount":244.0,"10th_percentile":195.2,"90th_percentile":608.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"239","median_amount":23.33,"10th_percentile":23.0,"90th_percentile":124.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.38,"10th_percentile":88.38,"90th_percentile":88.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.68,"10th_percentile":88.38,"90th_percentile":89.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"682","median_amount":88.88,"10th_percentile":69.47,"90th_percentile":176.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"40","median_amount":72.68,"10th_percentile":72.11,"90th_percentile":197.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"127","median_amount":427.5,"10th_percentile":427.5,"90th_percentile":855.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":381.69,"10th_percentile":381.69,"90th_percentile":442.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":7535.46,"10th_percentile":7535.46,"90th_percentile":7611.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":115.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"342","median_amount":107.56,"10th_percentile":85.54,"90th_percentile":215.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"284","median_amount":663.56,"10th_percentile":106.57,"90th_percentile":2244.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"525","median_amount":551.0,"10th_percentile":93.39,"90th_percentile":1578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":585.0,"10th_percentile":585.0,"90th_percentile":585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"123","median_amount":47.37,"10th_percentile":36.23,"90th_percentile":129.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":47.68,"10th_percentile":47.68,"90th_percentile":47.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":49.19,"10th_percentile":43.43,"90th_percentile":119.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"52","median_amount":756.5,"10th_percentile":403.75,"90th_percentile":2310.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":45.41,"10th_percentile":23.33,"90th_percentile":132.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"28","median_amount":107.56,"10th_percentile":100.43,"90th_percentile":197.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"104","median_amount":210.74,"10th_percentile":174.49,"90th_percentile":361.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"166","median_amount":468.0,"10th_percentile":353.39,"90th_percentile":1767.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"13","median_amount":636.83,"10th_percentile":468.0,"90th_percentile":1778.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"363","median_amount":109.76,"10th_percentile":101.23,"90th_percentile":291.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":45.11,"10th_percentile":34.5,"90th_percentile":132.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":106.93,"10th_percentile":106.93,"90th_percentile":177.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":69.96,"10th_percentile":69.96,"90th_percentile":69.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":86.05,"10th_percentile":86.05,"90th_percentile":109.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"35","median_amount":642.06,"10th_percentile":289.27,"90th_percentile":1690.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"114","median_amount":47.37,"10th_percentile":24.5,"90th_percentile":83.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2373","median_amount":108.36,"10th_percentile":86.05,"90th_percentile":250.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"218","median_amount":597.29,"10th_percentile":427.5,"90th_percentile":2029.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"88","median_amount":877.56,"10th_percentile":399.08,"90th_percentile":2660.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"33","median_amount":44.04,"10th_percentile":23.33,"90th_percentile":113.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":546.75,"10th_percentile":546.75,"90th_percentile":546.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"28","median_amount":667.5,"10th_percentile":350.0,"90th_percentile":1863.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1462","median_amount":430.0,"10th_percentile":206.0,"90th_percentile":1774.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"274","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":113.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":109.03,"10th_percentile":109.03,"90th_percentile":109.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1293","median_amount":108.0,"10th_percentile":86.05,"90th_percentile":215.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"125","median_amount":109.06,"10th_percentile":87.25,"90th_percentile":199.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"82","median_amount":465.5,"10th_percentile":427.5,"90th_percentile":2544.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"16","median_amount":1533.37,"10th_percentile":500.0,"90th_percentile":2544.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":137.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"118","median_amount":225.49,"10th_percentile":53.39,"90th_percentile":323.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"102","median_amount":3200.0,"10th_percentile":1203.5,"90th_percentile":3730.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"250","median_amount":2641.0,"10th_percentile":1276.52,"90th_percentile":2802.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2688.77,"10th_percentile":2688.77,"90th_percentile":2688.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"45","median_amount":104.11,"10th_percentile":104.11,"90th_percentile":210.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2814.0,"10th_percentile":2814.0,"90th_percentile":2814.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2814.0,"10th_percentile":1951.0,"90th_percentile":2898.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":104.11,"10th_percentile":100.26,"90th_percentile":256.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"17","median_amount":2528.0,"10th_percentile":1808.8,"90th_percentile":3254.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":100.26,"10th_percentile":99.15,"90th_percentile":126.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":238.32,"10th_percentile":231.79,"90th_percentile":498.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"121","median_amount":466.91,"10th_percentile":449.59,"90th_percentile":1004.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"58","median_amount":2130.0,"10th_percentile":1826.0,"90th_percentile":2598.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1302.7,"10th_percentile":1302.7,"90th_percentile":2130.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"142","median_amount":245.29,"10th_percentile":203.48,"90th_percentile":352.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":231.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":182.63,"10th_percentile":182.63,"90th_percentile":182.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":244.49,"10th_percentile":244.49,"90th_percentile":419.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"18","median_amount":3005.85,"10th_percentile":2168.91,"90th_percentile":5768.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"46","median_amount":104.11,"10th_percentile":104.11,"90th_percentile":189.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"794","median_amount":245.29,"10th_percentile":224.89,"90th_percentile":278.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"114","median_amount":2652.25,"10th_percentile":1479.48,"90th_percentile":2652.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"30","median_amount":3718.36,"10th_percentile":1457.66,"90th_percentile":5716.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":297.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2433.0,"10th_percentile":2433.0,"90th_percentile":2433.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"17","median_amount":2565.0,"10th_percentile":2225.25,"90th_percentile":2764.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"730","median_amount":2528.0,"10th_percentile":1229.2,"90th_percentile":2826.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"118","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":132.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"493","median_amount":244.5,"10th_percentile":190.65,"90th_percentile":350.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"42","median_amount":199.51,"10th_percentile":186.29,"90th_percentile":433.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"83","median_amount":3109.5,"10th_percentile":2591.25,"90th_percentile":3500.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3040.0,"10th_percentile":2035.65,"90th_percentile":3743.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":194.2,"10th_percentile":179.94,"90th_percentile":388.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"68","median_amount":528.4,"10th_percentile":424.73,"90th_percentile":560.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"26","median_amount":2434.78,"10th_percentile":1947.82,"90th_percentile":3160.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":203.91,"10th_percentile":188.94,"90th_percentile":407.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2183.0,"10th_percentile":2183.0,"90th_percentile":2248.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":203.91,"10th_percentile":203.91,"90th_percentile":203.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":2619.7,"10th_percentile":2072.38,"90th_percentile":4931.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":234.4,"10th_percentile":234.4,"90th_percentile":234.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":536.53,"10th_percentile":517.83,"90th_percentile":555.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"22","median_amount":1086.55,"10th_percentile":1019.81,"90th_percentile":1092.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"17","median_amount":2292.93,"10th_percentile":2292.93,"90th_percentile":2496.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2398.38,"10th_percentile":2292.93,"90th_percentile":2504.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"99","median_amount":539.03,"10th_percentile":407.59,"90th_percentile":621.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":357.68,"10th_percentile":357.68,"90th_percentile":527.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":429.22,"10th_percentile":429.22,"90th_percentile":429.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2681.34,"10th_percentile":2681.34,"90th_percentile":3573.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":9787.68,"10th_percentile":9787.68,"90th_percentile":9787.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":203.91,"10th_percentile":188.94,"90th_percentile":203.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"541","median_amount":555.39,"10th_percentile":515.39,"90th_percentile":601.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"32","median_amount":2175.89,"10th_percentile":1733.3,"90th_percentile":3445.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":2188.22,"10th_percentile":2068.19,"90th_percentile":2188.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":262.53,"10th_percentile":262.53,"90th_percentile":433.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2311.5,"10th_percentile":2311.5,"90th_percentile":5940.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"195","median_amount":2141.99,"10th_percentile":1515.1,"90th_percentile":2606.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":194.2,"10th_percentile":179.94,"90th_percentile":433.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"315","median_amount":554.6,"10th_percentile":339.0,"90th_percentile":649.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":452.54,"10th_percentile":422.56,"90th_percentile":565.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":2225.2,"10th_percentile":2225.2,"90th_percentile":5772.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":132.67,"10th_percentile":48.08,"90th_percentile":265.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"81","median_amount":183.74,"10th_percentile":144.05,"90th_percentile":444.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"30","median_amount":2690.59,"10th_percentile":858.2,"90th_percentile":4976.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"93","median_amount":1891.15,"10th_percentile":562.73,"90th_percentile":3227.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1707.93,"10th_percentile":1707.93,"90th_percentile":1707.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":278.6,"10th_percentile":132.64,"90th_percentile":343.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"11","median_amount":2666.88,"10th_percentile":2442.27,"90th_percentile":5547.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":126.32,"10th_percentile":126.32,"90th_percentile":154.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":183.74,"10th_percentile":182.34,"90th_percentile":395.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"56","median_amount":352.78,"10th_percentile":331.11,"90th_percentile":862.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"19","median_amount":2085.47,"10th_percentile":2000.17,"90th_percentile":4121.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2397.59,"10th_percentile":2122.67,"90th_percentile":6485.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"95","median_amount":267.33,"10th_percentile":142.8,"90th_percentile":447.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.67,"10th_percentile":126.32,"90th_percentile":813.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":436.47,"10th_percentile":436.47,"90th_percentile":436.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":134.5,"10th_percentile":134.5,"90th_percentile":134.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2661.51,"10th_percentile":1449.36,"90th_percentile":6228.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":139.3,"10th_percentile":50.48,"90th_percentile":278.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"508","median_amount":183.74,"10th_percentile":171.56,"90th_percentile":446.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"35","median_amount":2318.36,"10th_percentile":582.95,"90th_percentile":2426.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":2891.34,"10th_percentile":1322.0,"90th_percentile":5479.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":154.34,"10th_percentile":23.33,"90th_percentile":498.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7823.06,"10th_percentile":7823.06,"90th_percentile":7823.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2747.38,"10th_percentile":2320.12,"90th_percentile":4660.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"220","median_amount":1810.4,"10th_percentile":309.85,"90th_percentile":4435.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"59","median_amount":163.48,"10th_percentile":126.32,"90th_percentile":326.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":436.48,"10th_percentile":436.48,"90th_percentile":436.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"283","median_amount":183.74,"10th_percentile":151.34,"90th_percentile":441.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"28","median_amount":183.66,"10th_percentile":145.81,"90th_percentile":359.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2987.11,"10th_percentile":2987.11,"90th_percentile":2987.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4168.0,"10th_percentile":4168.0,"90th_percentile":4168.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":452.14,"10th_percentile":452.14,"90th_percentile":452.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":507.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"115","median_amount":365.14,"10th_percentile":269.83,"90th_percentile":691.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"86","median_amount":3728.04,"10th_percentile":2072.04,"90th_percentile":5335.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"201","median_amount":2827.47,"10th_percentile":1242.14,"90th_percentile":3386.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3098.24,"10th_percentile":3098.24,"90th_percentile":3098.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":175.11,"10th_percentile":139.3,"90th_percentile":177.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2152.32,"10th_percentile":2025.94,"90th_percentile":3064.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":214.06,"10th_percentile":204.3,"90th_percentile":535.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"31","median_amount":2849.2,"10th_percentile":1265.64,"90th_percentile":6004.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":333.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"13","median_amount":366.24,"10th_percentile":182.86,"90th_percentile":539.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"125","median_amount":707.71,"10th_percentile":664.25,"90th_percentile":1662.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"55","median_amount":2498.09,"10th_percentile":2104.63,"90th_percentile":2658.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"14","median_amount":2683.27,"10th_percentile":2226.94,"90th_percentile":4639.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"139","median_amount":368.24,"10th_percentile":125.8,"90th_percentile":548.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":416.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":299.22,"10th_percentile":299.22,"90th_percentile":374.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"13","median_amount":3094.81,"10th_percentile":2471.53,"90th_percentile":3768.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":175.11,"10th_percentile":132.64,"90th_percentile":458.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"813","median_amount":367.24,"10th_percentile":115.16,"90th_percentile":575.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"61","median_amount":2457.27,"10th_percentile":2164.24,"90th_percentile":3074.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"30","median_amount":4025.24,"10th_percentile":2872.17,"90th_percentile":7479.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":163.48,"10th_percentile":132.67,"90th_percentile":338.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2812.5,"10th_percentile":2812.5,"90th_percentile":2812.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"16","median_amount":2765.65,"10th_percentile":2434.12,"90th_percentile":5380.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"589","median_amount":2576.63,"10th_percentile":1333.66,"90th_percentile":4345.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":333.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":376.23,"10th_percentile":376.23,"90th_percentile":376.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":653.92,"10th_percentile":653.92,"90th_percentile":653.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"425","median_amount":365.64,"10th_percentile":220.64,"90th_percentile":757.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":294.76,"10th_percentile":275.22,"90th_percentile":692.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"11","median_amount":3685.73,"10th_percentile":2542.58,"90th_percentile":5108.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3695.67,"10th_percentile":2628.91,"90th_percentile":7481.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":194.2,"10th_percentile":194.2,"90th_percentile":389.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"22","median_amount":799.12,"10th_percentile":639.29,"90th_percentile":1017.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":3398.38,"10th_percentile":1996.02,"90th_percentile":5891.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"43","median_amount":2495.02,"10th_percentile":1870.04,"90th_percentile":5417.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":203.91,"10th_percentile":203.91,"90th_percentile":747.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":351.79,"10th_percentile":351.79,"90th_percentile":351.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":4104.65,"10th_percentile":3478.84,"90th_percentile":4605.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":394.42,"10th_percentile":394.42,"90th_percentile":683.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":799.12,"10th_percentile":799.12,"90th_percentile":799.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1565.64,"10th_percentile":1469.46,"90th_percentile":5260.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"14","median_amount":3654.77,"10th_percentile":3044.9,"90th_percentile":4010.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3389.6,"10th_percentile":3389.6,"90th_percentile":3389.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":799.12,"10th_percentile":652.12,"90th_percentile":945.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":389.25,"10th_percentile":194.2,"90th_percentile":424.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1205.57,"10th_percentile":1205.57,"90th_percentile":1205.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":203.91,"90th_percentile":748.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"173","median_amount":799.72,"10th_percentile":746.95,"90th_percentile":839.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"12","median_amount":3036.37,"10th_percentile":2334.0,"90th_percentile":4632.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3257.96,"10th_percentile":3054.24,"90th_percentile":6002.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":394.42,"10th_percentile":394.42,"90th_percentile":394.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7330.68,"10th_percentile":7330.68,"90th_percentile":10033.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"111","median_amount":2989.2,"10th_percentile":1948.51,"90th_percentile":3690.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":389.25,"10th_percentile":194.2,"90th_percentile":394.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"95","median_amount":799.13,"10th_percentile":639.29,"90th_percentile":909.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":652.08,"10th_percentile":652.08,"90th_percentile":815.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"13","median_amount":4418.11,"10th_percentile":4412.26,"90th_percentile":4885.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":418.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":410.95,"10th_percentile":401.11,"90th_percentile":771.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":1120.58,"10th_percentile":890.35,"90th_percentile":5968.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1020.48,"10th_percentile":829.56,"90th_percentile":4260.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":160.34,"10th_percentile":160.34,"90th_percentile":160.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3393.37,"10th_percentile":3393.37,"90th_percentile":3393.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":796.3,"10th_percentile":796.3,"90th_percentile":800.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":411.45,"10th_percentile":384.5,"90th_percentile":634.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":320.89,"10th_percentile":320.89,"90th_percentile":320.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":3276.42,"10th_percentile":3276.42,"90th_percentile":3276.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":425.62,"10th_percentile":160.34,"90th_percentile":438.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"63","median_amount":412.35,"10th_percentile":179.69,"90th_percentile":846.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3646.2,"10th_percentile":3567.48,"90th_percentile":6973.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9334.3,"10th_percentile":3972.58,"90th_percentile":9734.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"26","median_amount":3588.75,"10th_percentile":2666.66,"90th_percentile":6332.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":777.25,"10th_percentile":777.25,"90th_percentile":777.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"35","median_amount":771.09,"10th_percentile":325.15,"90th_percentile":1212.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":414.57,"10th_percentile":331.65,"90th_percentile":690.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":196.86,"10th_percentile":196.86,"90th_percentile":196.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":406.68,"10th_percentile":406.68,"90th_percentile":406.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1675.75,"10th_percentile":1675.75,"90th_percentile":1675.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":892.95,"10th_percentile":647.75,"90th_percentile":1660.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":160.34,"10th_percentile":160.34,"90th_percentile":202.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":3199.4,"10th_percentile":3199.4,"90th_percentile":3199.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":597.11,"10th_percentile":597.11,"90th_percentile":597.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1066.68,"10th_percentile":1066.68,"90th_percentile":1066.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3073.9,"10th_percentile":3073.9,"90th_percentile":3073.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3412.79,"10th_percentile":3412.79,"90th_percentile":3412.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":530.66,"10th_percentile":530.66,"90th_percentile":977.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":206.71,"10th_percentile":206.71,"90th_percentile":206.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":544.45,"10th_percentile":514.26,"90th_percentile":618.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3893.3,"10th_percentile":3849.7,"90th_percentile":3975.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4222.15,"10th_percentile":4222.15,"90th_percentile":4222.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":399.36,"10th_percentile":399.36,"90th_percentile":399.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2996.1,"10th_percentile":2996.1,"90th_percentile":2996.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"23","median_amount":2922.37,"10th_percentile":2346.7,"90th_percentile":3795.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":192.99,"10th_percentile":192.99,"90th_percentile":196.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":547.85,"10th_percentile":435.56,"90th_percentile":678.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"43","median_amount":1237.43,"10th_percentile":1056.38,"90th_percentile":1384.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"20","median_amount":3659.04,"10th_percentile":2414.39,"90th_percentile":4116.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"42","median_amount":2954.12,"10th_percentile":2074.85,"90th_percentile":3009.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":469.4,"10th_percentile":469.4,"90th_percentile":673.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":5333.28,"10th_percentile":4277.25,"90th_percentile":7125.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1384.99,"10th_percentile":1237.93,"90th_percentile":1559.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"27","median_amount":2587.05,"10th_percentile":2428.11,"90th_percentile":2705.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5474.16,"10th_percentile":5474.16,"90th_percentile":5854.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5854.14,"10th_percentile":5854.14,"90th_percentile":5854.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"53","median_amount":1325.47,"10th_percentile":1075.47,"90th_percentile":1453.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1160.66,"10th_percentile":1160.66,"90th_percentile":1160.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":434.57,"10th_percentile":434.57,"90th_percentile":434.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":6845.82,"10th_percentile":6294.02,"90th_percentile":10143.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":6254.31,"10th_percentile":6254.31,"90th_percentile":6254.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":469.4,"10th_percentile":469.4,"90th_percentile":469.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"316","median_amount":1326.37,"10th_percentile":531.78,"90th_percentile":1386.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"12","median_amount":6174.93,"10th_percentile":5927.09,"90th_percentile":7431.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6222.44,"10th_percentile":6222.44,"90th_percentile":6222.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5458.51,"10th_percentile":5458.51,"90th_percentile":5458.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"103","median_amount":5124.08,"10th_percentile":3365.61,"90th_percentile":5153.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1075.48,"10th_percentile":1075.48,"90th_percentile":1075.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"189","median_amount":1323.88,"10th_percentile":1056.38,"90th_percentile":1384.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"17","median_amount":1077.51,"10th_percentile":1077.51,"90th_percentile":1165.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":5901.56,"10th_percentile":5901.56,"90th_percentile":5901.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Nuclear Medicine and Related Services","code_information":[{"code":"5594","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":600.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"31","median_amount":1381.43,"10th_percentile":1180.26,"90th_percentile":1525.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9342.29,"10th_percentile":9342.29,"90th_percentile":15402.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"23","median_amount":5803.22,"10th_percentile":5176.96,"90th_percentile":9198.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":606.15,"10th_percentile":606.15,"90th_percentile":606.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.37,"10th_percentile":554.37,"90th_percentile":554.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":5952.5,"10th_percentile":5652.5,"90th_percentile":7700.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1405.51,"10th_percentile":1230.33,"90th_percentile":6665.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"19","median_amount":2980.92,"10th_percentile":2712.89,"90th_percentile":8679.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6739.65,"10th_percentile":6739.65,"90th_percentile":6739.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":6482.09,"10th_percentile":6482.09,"90th_percentile":6482.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"34","median_amount":1482.33,"10th_percentile":1132.33,"90th_percentile":3420.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1407.86,"10th_percentile":1407.86,"90th_percentile":1407.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":16464.76,"10th_percentile":16464.76,"90th_percentile":16464.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":606.15,"10th_percentile":606.15,"90th_percentile":606.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"173","median_amount":1481.33,"10th_percentile":1186.23,"90th_percentile":4413.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8350.75,"10th_percentile":8000.25,"90th_percentile":8469.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9027.01,"10th_percentile":7989.91,"90th_percentile":11687.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6114.83,"10th_percentile":6114.83,"90th_percentile":6114.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"56","median_amount":5772.02,"10th_percentile":5691.55,"90th_percentile":10019.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.37,"10th_percentile":554.37,"90th_percentile":744.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4412.47,"10th_percentile":4412.47,"90th_percentile":4412.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"90","median_amount":1475.34,"10th_percentile":1180.26,"90th_percentile":4411.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1223.82,"10th_percentile":1203.87,"90th_percentile":1504.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":8389.3,"10th_percentile":8389.3,"90th_percentile":8389.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5611","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5244.79,"10th_percentile":5244.79,"90th_percentile":5244.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5612","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":700.24,"10th_percentile":700.24,"90th_percentile":870.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1811.79,"10th_percentile":1811.79,"90th_percentile":19146.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8640.71,"10th_percentile":8640.71,"90th_percentile":8640.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1098.68,"10th_percentile":1098.68,"90th_percentile":1098.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":722.77,"10th_percentile":722.77,"90th_percentile":722.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12702.52,"10th_percentile":12702.52,"90th_percentile":12702.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1184.86,"10th_percentile":371.78,"90th_percentile":8871.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1619.94,"10th_percentile":1619.94,"90th_percentile":1619.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"27","median_amount":1989.26,"10th_percentile":502.13,"90th_percentile":7210.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17144.73,"10th_percentile":17144.73,"90th_percentile":32568.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":12193.04,"10th_percentile":1089.5,"90th_percentile":37121.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1177.42,"10th_percentile":1177.42,"90th_percentile":2190.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"20","median_amount":1128.74,"10th_percentile":371.79,"90th_percentile":8348.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5613","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2661.72,"10th_percentile":2086.35,"90th_percentile":5271.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3845.7,"10th_percentile":3845.7,"90th_percentile":3845.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8463.26,"10th_percentile":8463.26,"90th_percentile":8463.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4688.51,"10th_percentile":4400.51,"90th_percentile":5963.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":15169.6,"10th_percentile":15169.6,"90th_percentile":15169.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3146.44,"10th_percentile":2339.73,"90th_percentile":3577.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":16319.46,"10th_percentile":16319.46,"90th_percentile":16319.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":652.72,"10th_percentile":652.72,"90th_percentile":652.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"20","median_amount":3146.44,"10th_percentile":1385.7,"90th_percentile":4136.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":13100.67,"10th_percentile":13100.67,"90th_percentile":13100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":13378.76,"10th_percentile":13378.76,"90th_percentile":16623.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"15","median_amount":2672.6,"10th_percentile":2129.39,"90th_percentile":3968.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1952.78,"10th_percentile":1952.78,"90th_percentile":1952.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Radiation Therapy","code_information":[{"code":"5622","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1410.48,"10th_percentile":1410.48,"90th_percentile":1458.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3928.23,"10th_percentile":3531.55,"90th_percentile":4576.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":14087.9,"10th_percentile":4040.5,"90th_percentile":22224.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":18193.79,"10th_percentile":11503.17,"90th_percentile":23924.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1544.41,"10th_percentile":1544.41,"90th_percentile":1544.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":697.5,"10th_percentile":697.5,"90th_percentile":697.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":27473.7,"10th_percentile":27473.7,"90th_percentile":27473.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9933.24,"10th_percentile":9933.24,"90th_percentile":10954.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4712.41,"10th_percentile":932.3,"90th_percentile":10109.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":25510.14,"10th_percentile":25510.14,"90th_percentile":25510.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"54","median_amount":4135.34,"10th_percentile":1171.44,"90th_percentile":8879.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":26668.34,"10th_percentile":26668.34,"90th_percentile":26668.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":34097.04,"10th_percentile":4458.09,"90th_percentile":37728.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"24","median_amount":18177.73,"10th_percentile":7103.64,"90th_percentile":36219.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2323.24,"10th_percentile":2323.24,"90th_percentile":2323.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":3640.22,"10th_percentile":919.68,"90th_percentile":8149.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6405.99,"10th_percentile":6405.99,"90th_percentile":6405.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":14224.11,"10th_percentile":14224.11,"90th_percentile":14224.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Radiation Therapy","code_information":[{"code":"5623","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":7838.41,"10th_percentile":1037.82,"90th_percentile":13409.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":26069.4,"10th_percentile":26069.4,"90th_percentile":26069.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":14595.39,"10th_percentile":4188.54,"90th_percentile":24580.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4717.07,"10th_percentile":4717.07,"90th_percentile":4717.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12958.81,"10th_percentile":12958.81,"90th_percentile":12958.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":13748.69,"10th_percentile":11989.6,"90th_percentile":26673.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":7665.11,"10th_percentile":3533.63,"90th_percentile":12856.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":80311.44,"10th_percentile":80311.44,"90th_percentile":98482.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4079.52,"10th_percentile":4079.52,"90th_percentile":4079.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"123","median_amount":8257.24,"10th_percentile":1833.14,"90th_percentile":12958.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":57193.43,"10th_percentile":57193.43,"90th_percentile":69625.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":51853.35,"10th_percentile":19444.0,"90th_percentile":74364.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2705.2,"10th_percentile":2705.2,"90th_percentile":2705.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"76","median_amount":8122.17,"10th_percentile":1889.63,"90th_percentile":13464.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8554.97,"10th_percentile":1909.8,"90th_percentile":8813.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Radiation Therapy","code_information":[{"code":"5626","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5790.84,"10th_percentile":5683.4,"90th_percentile":9171.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":13030.23,"10th_percentile":13030.23,"90th_percentile":13030.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":42753.2,"10th_percentile":42753.2,"90th_percentile":42753.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9014.6,"10th_percentile":9014.6,"90th_percentile":9014.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1826.5,"10th_percentile":1826.5,"90th_percentile":1826.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7073.45,"10th_percentile":4553.51,"90th_percentile":11762.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6941.52,"10th_percentile":3980.01,"90th_percentile":9014.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":33345.56,"10th_percentile":33345.56,"90th_percentile":33345.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 7 Radiation Therapy","code_information":[{"code":"5627","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14096.52,"10th_percentile":14096.52,"90th_percentile":14096.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":55.14,"10th_percentile":55.14,"90th_percentile":55.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":109.81,"10th_percentile":109.81,"90th_percentile":109.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":61.28,"10th_percentile":61.28,"90th_percentile":61.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":34.44,"10th_percentile":34.44,"90th_percentile":54.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":49.47,"10th_percentile":49.47,"90th_percentile":49.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":52.71,"10th_percentile":52.71,"90th_percentile":52.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pathology","code_information":[{"code":"5672","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.33,"10th_percentile":173.33,"90th_percentile":173.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":22819.24,"10th_percentile":22819.24,"90th_percentile":22819.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.73,"10th_percentile":173.73,"90th_percentile":173.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":369.05,"10th_percentile":369.05,"90th_percentile":369.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.34,"10th_percentile":173.34,"90th_percentile":173.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":232.48,"10th_percentile":232.48,"90th_percentile":232.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":294.0,"10th_percentile":294.0,"90th_percentile":294.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":363.85,"10th_percentile":363.85,"90th_percentile":363.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":296.91,"10th_percentile":296.91,"90th_percentile":296.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":55.33,"10th_percentile":55.33,"90th_percentile":55.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5345.31,"10th_percentile":5345.31,"90th_percentile":5345.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":446.5,"10th_percentile":446.5,"90th_percentile":446.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":415.3,"10th_percentile":415.3,"90th_percentile":491.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7390.17,"10th_percentile":7390.17,"90th_percentile":7390.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":204.01,"10th_percentile":21.36,"90th_percentile":535.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":260.7,"10th_percentile":71.98,"90th_percentile":1714.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":907.08,"10th_percentile":706.26,"90th_percentile":7162.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":2667.28,"10th_percentile":85.27,"90th_percentile":7134.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":96.39,"10th_percentile":60.6,"90th_percentile":238.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":86.98,"10th_percentile":86.98,"90th_percentile":86.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":161.7,"10th_percentile":161.7,"90th_percentile":277.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2440.74,"10th_percentile":2285.61,"90th_percentile":2916.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":543.65,"10th_percentile":543.65,"90th_percentile":548.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":137.45,"10th_percentile":132.98,"90th_percentile":2299.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"28","median_amount":486.82,"10th_percentile":88.11,"90th_percentile":2654.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.38,"10th_percentile":92.38,"90th_percentile":92.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1222.56,"10th_percentile":1222.56,"90th_percentile":1222.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":67.29,"10th_percentile":67.29,"90th_percentile":211.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"153","median_amount":282.57,"10th_percentile":71.98,"90th_percentile":2542.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":483.28,"10th_percentile":483.28,"90th_percentile":483.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":820.94,"10th_percentile":820.94,"90th_percentile":820.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":204.01,"10th_percentile":122.03,"90th_percentile":327.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1003.38,"10th_percentile":1003.38,"90th_percentile":1003.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"61","median_amount":132.6,"10th_percentile":63.12,"90th_percentile":1733.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":117.12,"10th_percentile":19.24,"90th_percentile":306.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21.34,"10th_percentile":10.67,"90th_percentile":523.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"112","median_amount":1419.63,"10th_percentile":139.82,"90th_percentile":2547.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":398.88,"10th_percentile":132.96,"90th_percentile":1441.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"13","median_amount":992.15,"10th_percentile":505.81,"90th_percentile":1269.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":8421.76,"10th_percentile":8421.76,"90th_percentile":8421.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":5983.09,"10th_percentile":5983.09,"90th_percentile":5983.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":450.56,"10th_percentile":161.49,"90th_percentile":1317.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"58","median_amount":928.65,"10th_percentile":213.11,"90th_percentile":6354.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"25","median_amount":1322.07,"10th_percentile":520.81,"90th_percentile":3181.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"77","median_amount":884.32,"10th_percentile":347.23,"90th_percentile":4923.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"42","median_amount":815.81,"10th_percentile":201.32,"90th_percentile":2204.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":6561.63,"10th_percentile":5908.66,"90th_percentile":19195.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":521.62,"10th_percentile":521.62,"90th_percentile":521.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":848.52,"10th_percentile":762.03,"90th_percentile":3705.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":457.64,"10th_percentile":457.64,"90th_percentile":516.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":213.11,"10th_percentile":208.46,"90th_percentile":962.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"19","median_amount":10369.07,"10th_percentile":1367.12,"90th_percentile":113783.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"17","median_amount":2059.12,"10th_percentile":424.08,"90th_percentile":14135.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1517.31,"10th_percentile":1517.31,"90th_percentile":1517.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"98","median_amount":2354.81,"10th_percentile":213.55,"90th_percentile":27757.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":329.45,"10th_percentile":234.66,"90th_percentile":564.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":274.77,"10th_percentile":274.77,"90th_percentile":274.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":170.49,"10th_percentile":170.49,"90th_percentile":170.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2966.7,"10th_percentile":2966.7,"90th_percentile":2966.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"29","median_amount":301.07,"10th_percentile":123.2,"90th_percentile":2004.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"282","median_amount":761.18,"10th_percentile":208.46,"90th_percentile":4864.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"24","median_amount":2105.92,"10th_percentile":654.98,"90th_percentile":4455.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1786.84,"10th_percentile":1079.33,"90th_percentile":4456.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":343.09,"10th_percentile":343.09,"90th_percentile":499.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5724.92,"10th_percentile":2605.13,"90th_percentile":17301.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"179","median_amount":1684.38,"10th_percentile":327.16,"90th_percentile":6668.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"91","median_amount":908.93,"10th_percentile":212.12,"90th_percentile":2292.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"208","median_amount":976.88,"10th_percentile":212.71,"90th_percentile":5378.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"19","median_amount":646.22,"10th_percentile":217.37,"90th_percentile":3686.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2861.42,"10th_percentile":1720.51,"90th_percentile":6295.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5227.91,"10th_percentile":5227.91,"90th_percentile":5227.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":513.13,"10th_percentile":513.13,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":931.14,"10th_percentile":670.99,"90th_percentile":1339.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2994.71,"10th_percentile":2612.34,"90th_percentile":17123.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2395.68,"10th_percentile":1610.41,"90th_percentile":3795.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":751.77,"10th_percentile":538.79,"90th_percentile":1503.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":524.24,"10th_percentile":524.24,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3062.38,"10th_percentile":2644.19,"90th_percentile":3347.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"23","median_amount":4455.49,"10th_percentile":3841.52,"90th_percentile":4937.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1971.63,"10th_percentile":834.94,"90th_percentile":2397.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":738.37,"10th_percentile":738.37,"90th_percentile":738.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.74,"10th_percentile":332.01,"90th_percentile":1109.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"83","median_amount":962.38,"10th_percentile":335.49,"90th_percentile":1914.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3620.01,"10th_percentile":2824.18,"90th_percentile":5484.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1235.37,"10th_percentile":1235.37,"90th_percentile":1235.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":2877.26,"10th_percentile":1384.89,"90th_percentile":6323.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":513.13,"10th_percentile":513.13,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"30","median_amount":1111.44,"10th_percentile":477.04,"90th_percentile":1350.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":63.4,"10th_percentile":28.05,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":130.0,"10th_percentile":65.16,"90th_percentile":158.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"33","median_amount":790.0,"10th_percentile":609.25,"90th_percentile":1000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"71","median_amount":1000.0,"10th_percentile":447.3,"90th_percentile":1000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":770.0,"10th_percentile":770.0,"90th_percentile":770.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":66.57,"10th_percentile":25.2,"90th_percentile":66.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":830.0,"10th_percentile":830.0,"90th_percentile":830.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":850.0,"10th_percentile":850.0,"90th_percentile":850.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.08,"10th_percentile":63.08,"90th_percentile":63.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":151.92,"10th_percentile":151.92,"90th_percentile":158.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":297.64,"10th_percentile":297.64,"90th_percentile":297.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"18","median_amount":743.97,"10th_percentile":743.97,"90th_percentile":866.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":717.19,"10th_percentile":717.19,"90th_percentile":743.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":153.62,"10th_percentile":126.61,"90th_percentile":161.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.4,"10th_percentile":63.4,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":870.0,"10th_percentile":188.79,"90th_percentile":900.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":66.57,"10th_percentile":25.2,"90th_percentile":66.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"78","median_amount":158.36,"10th_percentile":126.61,"90th_percentile":159.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"45","median_amount":706.0,"10th_percentile":635.4,"90th_percentile":964.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":710.0,"10th_percentile":710.0,"90th_percentile":888.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.08,"10th_percentile":63.08,"90th_percentile":63.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":750.0,"10th_percentile":325.5,"90th_percentile":873.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"208","median_amount":695.0,"10th_percentile":301.63,"90th_percentile":811.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":63.08,"10th_percentile":23.15,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"109","median_amount":152.62,"10th_percentile":121.54,"90th_percentile":159.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":129.14,"10th_percentile":120.58,"90th_percentile":150.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":89.69,"10th_percentile":79.79,"90th_percentile":508.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"29","median_amount":314.97,"10th_percentile":244.21,"90th_percentile":314.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"16","median_amount":1264.0,"10th_percentile":781.38,"90th_percentile":1607.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"48","median_amount":1013.84,"10th_percentile":605.82,"90th_percentile":1244.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.68,"10th_percentile":74.22,"90th_percentile":94.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":736.0,"10th_percentile":736.0,"90th_percentile":736.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1141.0,"10th_percentile":866.0,"90th_percentile":1293.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1674.7,"10th_percentile":1360.0,"90th_percentile":2833.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":89.69,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":305.26,"10th_percentile":305.26,"90th_percentile":305.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"34","median_amount":617.09,"10th_percentile":579.19,"90th_percentile":620.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"16","median_amount":1513.62,"10th_percentile":1190.36,"90th_percentile":2022.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1250.76,"10th_percentile":1250.76,"90th_percentile":1250.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"40","median_amount":314.97,"10th_percentile":270.96,"90th_percentile":315.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":79.79,"10th_percentile":79.79,"90th_percentile":1016.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1520.76,"10th_percentile":1252.8,"90th_percentile":1836.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":83.78,"10th_percentile":74.22,"90th_percentile":94.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"209","median_amount":306.06,"10th_percentile":294.5,"90th_percentile":315.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"19","median_amount":1306.1,"10th_percentile":1016.64,"90th_percentile":2067.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"12","median_amount":1241.08,"10th_percentile":1096.02,"90th_percentile":1822.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":89.69,"10th_percentile":89.69,"90th_percentile":1016.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1400.79,"10th_percentile":1400.79,"90th_percentile":1574.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"120","median_amount":1214.87,"10th_percentile":895.52,"90th_percentile":1539.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"25","median_amount":85.79,"10th_percentile":70.69,"90th_percentile":89.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":235.28,"10th_percentile":235.28,"90th_percentile":235.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"134","median_amount":305.27,"10th_percentile":244.21,"90th_percentile":315.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":257.01,"10th_percentile":239.98,"90th_percentile":257.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1831.05,"10th_percentile":1831.05,"90th_percentile":1985.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1262.06,"10th_percentile":1262.06,"90th_percentile":1262.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Diagnostic Tests and Related Services","code_information":[{"code":"5723","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.86,"10th_percentile":68.86,"90th_percentile":68.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":417.02,"10th_percentile":417.02,"90th_percentile":417.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1615.55,"10th_percentile":1615.55,"90th_percentile":1667.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1225.11,"10th_percentile":1225.11,"90th_percentile":1225.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":519.36,"10th_percentile":519.36,"90th_percentile":519.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":161.62,"10th_percentile":161.62,"90th_percentile":161.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1795.41,"10th_percentile":1795.41,"90th_percentile":1795.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.86,"10th_percentile":68.86,"90th_percentile":68.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":544.49,"10th_percentile":544.49,"90th_percentile":544.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1021.27,"10th_percentile":1021.27,"90th_percentile":1051.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2321.84,"10th_percentile":2321.84,"90th_percentile":2321.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":527.27,"10th_percentile":527.27,"90th_percentile":527.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":155.86,"10th_percentile":155.86,"90th_percentile":155.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":537.09,"10th_percentile":521.51,"90th_percentile":726.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2110.5,"10th_percentile":2105.0,"90th_percentile":2650.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1499.7,"10th_percentile":1499.7,"90th_percentile":1499.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1584.19,"10th_percentile":1584.19,"90th_percentile":1584.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"14","median_amount":1468.01,"10th_percentile":1462.98,"90th_percentile":2172.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"11","median_amount":492.59,"10th_percentile":429.35,"90th_percentile":521.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":437.93,"10th_percentile":437.93,"90th_percentile":437.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":2243.35,"10th_percentile":2243.35,"90th_percentile":2243.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 Diagnostic Tests and Related Services","code_information":[{"code":"5724","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":317.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"16","median_amount":964.75,"10th_percentile":823.26,"90th_percentile":1033.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":5044.94,"10th_percentile":5014.94,"90th_percentile":5434.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"26","median_amount":3555.0,"10th_percentile":3021.75,"90th_percentile":3771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":333.18,"10th_percentile":333.18,"90th_percentile":333.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4657.66,"10th_percentile":4657.66,"90th_percentile":4657.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":5564.74,"10th_percentile":5546.47,"90th_percentile":5821.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":328.43,"10th_percentile":328.43,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1029.07,"10th_percentile":1029.07,"90th_percentile":1395.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5095.47,"10th_percentile":4751.01,"90th_percentile":5095.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":962.65,"10th_percentile":800.3,"90th_percentile":1030.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":333.18,"10th_percentile":333.18,"90th_percentile":344.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"96","median_amount":1017.24,"10th_percentile":343.29,"90th_percentile":1029.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"11","median_amount":4553.22,"10th_percentile":3832.67,"90th_percentile":4835.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4862.79,"10th_percentile":4534.06,"90th_percentile":5469.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1169.22,"10th_percentile":1169.22,"90th_percentile":5136.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":4482.97,"10th_percentile":3599.0,"90th_percentile":4808.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1017.54,"10th_percentile":1017.54,"90th_percentile":1017.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"72","median_amount":984.97,"10th_percentile":768.68,"90th_percentile":1030.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":839.72,"10th_percentile":839.72,"90th_percentile":839.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4191.73,"10th_percentile":4191.73,"90th_percentile":4191.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Minor Procedures","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19.82,"10th_percentile":19.82,"90th_percentile":19.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":114.28,"10th_percentile":114.28,"90th_percentile":114.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.77,"10th_percentile":24.77,"90th_percentile":24.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":14.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":243.25,"10th_percentile":243.25,"90th_percentile":243.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28.96,"10th_percentile":28.96,"90th_percentile":28.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":39.86,"10th_percentile":29.65,"90th_percentile":75.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":161.95,"10th_percentile":161.95,"90th_percentile":161.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"18","median_amount":118.9,"10th_percentile":95.12,"90th_percentile":118.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":26.94,"10th_percentile":26.94,"90th_percentile":26.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.66,"10th_percentile":25.66,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":174.25,"10th_percentile":174.25,"90th_percentile":174.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":77.78,"10th_percentile":77.78,"90th_percentile":78.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"11","median_amount":152.51,"10th_percentile":152.51,"90th_percentile":152.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":40.51,"10th_percentile":37.83,"90th_percentile":40.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":298.77,"10th_percentile":298.77,"90th_percentile":298.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.49,"10th_percentile":25.49,"90th_percentile":25.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"62","median_amount":40.2,"10th_percentile":37.83,"90th_percentile":40.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":144.73,"10th_percentile":144.73,"90th_percentile":144.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":145.55,"10th_percentile":145.55,"90th_percentile":145.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"43","median_amount":142.48,"10th_percentile":142.48,"90th_percentile":1201.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":42.66,"10th_percentile":24.28,"90th_percentile":144.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"45","median_amount":39.7,"10th_percentile":31.76,"90th_percentile":64.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32.4,"10th_percentile":32.4,"90th_percentile":32.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.66,"10th_percentile":24.28,"90th_percentile":39.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":60.08,"10th_percentile":47.59,"90th_percentile":144.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"24","median_amount":683.68,"10th_percentile":120.08,"90th_percentile":1516.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"94","median_amount":111.25,"10th_percentile":69.6,"90th_percentile":1113.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11.21,"10th_percentile":11.21,"90th_percentile":22.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1281.0,"10th_percentile":1281.0,"90th_percentile":1281.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1632.0,"10th_percentile":129.2,"90th_percentile":1632.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":113.52,"10th_percentile":113.52,"90th_percentile":113.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":59.49,"10th_percentile":59.49,"90th_percentile":60.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"21","median_amount":117.72,"10th_percentile":110.47,"90th_percentile":117.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1428.42,"10th_percentile":113.08,"90th_percentile":1428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1428.42,"10th_percentile":1428.42,"90th_percentile":1428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"33","median_amount":61.31,"10th_percentile":60.08,"90th_percentile":120.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.21,"10th_percentile":24.28,"90th_percentile":71.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":252.76,"10th_percentile":48.07,"90th_percentile":355.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":166.87,"10th_percentile":166.87,"90th_percentile":166.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.49,"10th_percentile":11.29,"90th_percentile":26.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"212","median_amount":60.88,"10th_percentile":56.9,"90th_percentile":240.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":1355.52,"10th_percentile":107.31,"90th_percentile":1355.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1363.2,"10th_percentile":1118.56,"90th_percentile":1363.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":205.5,"10th_percentile":205.5,"90th_percentile":1440.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"124","median_amount":1078.27,"10th_percentile":103.82,"90th_percentile":1347.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":24.28,"10th_percentile":10.75,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"110","median_amount":60.19,"10th_percentile":11.09,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":49.03,"10th_percentile":45.77,"90th_percentile":550.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":246.6,"10th_percentile":246.6,"90th_percentile":246.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1392.0,"10th_percentile":1392.0,"90th_percentile":1392.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":162.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":124.53,"10th_percentile":91.18,"90th_percentile":131.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"24","median_amount":556.16,"10th_percentile":204.16,"90th_percentile":767.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"56","median_amount":428.04,"10th_percentile":163.33,"90th_percentile":612.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":504.02,"10th_percentile":504.02,"90th_percentile":504.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":47.37,"10th_percentile":26.94,"90th_percentile":71.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":485.22,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":854.0,"10th_percentile":854.0,"90th_percentile":854.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":485.22,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":627.3,"10th_percentile":627.3,"90th_percentile":3798.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":124.23,"10th_percentile":124.23,"90th_percentile":124.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"20","median_amount":255.44,"10th_percentile":239.74,"90th_percentile":255.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":635.35,"10th_percentile":549.05,"90th_percentile":1431.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":549.05,"10th_percentile":549.05,"90th_percentile":691.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"38","median_amount":126.13,"10th_percentile":91.18,"90th_percentile":165.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":68.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":104.3,"10th_percentile":104.3,"90th_percentile":104.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":649.11,"10th_percentile":649.11,"90th_percentile":742.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":47.37,"10th_percentile":25.49,"90th_percentile":47.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"220","median_amount":130.38,"10th_percentile":109.36,"90th_percentile":142.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"17","median_amount":521.03,"10th_percentile":521.03,"90th_percentile":2085.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":606.34,"10th_percentile":558.42,"90th_percentile":606.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":570.4,"10th_percentile":281.6,"90th_percentile":640.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"108","median_amount":512.91,"10th_percentile":89.69,"90th_percentile":593.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":48.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"139","median_amount":126.34,"10th_percentile":97.39,"90th_percentile":133.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":106.39,"10th_percentile":106.39,"90th_percentile":132.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1418.25,"10th_percentile":1314.45,"90th_percentile":4355.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":25.66,"10th_percentile":25.66,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 Minor Procedures","code_information":[{"code":"5735","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":261.0,"10th_percentile":261.0,"90th_percentile":261.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":334.79,"10th_percentile":334.79,"90th_percentile":334.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Electronic Analysis of Devices","code_information":[{"code":"5741","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"206","median_amount":37.72,"10th_percentile":30.17,"90th_percentile":37.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"40","median_amount":174.59,"10th_percentile":128.18,"90th_percentile":183.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"72","median_amount":128.18,"10th_percentile":105.56,"90th_percentile":134.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":35.22,"10th_percentile":35.22,"90th_percentile":35.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":15.58,"10th_percentile":15.58,"90th_percentile":15.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":174.0,"10th_percentile":174.0,"90th_percentile":174.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17.33,"10th_percentile":15.03,"90th_percentile":17.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":187.85,"10th_percentile":154.7,"90th_percentile":221.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15.03,"10th_percentile":15.03,"90th_percentile":15.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":37.72,"10th_percentile":35.62,"90th_percentile":38.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"87","median_amount":73.9,"10th_percentile":69.36,"90th_percentile":74.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"15","median_amount":164.41,"10th_percentile":135.41,"90th_percentile":348.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":158.13,"10th_percentile":158.13,"90th_percentile":158.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"256","median_amount":37.8,"10th_percentile":33.01,"90th_percentile":38.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":15.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":37.87,"10th_percentile":37.87,"90th_percentile":37.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":30.17,"10th_percentile":29.34,"90th_percentile":37.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":144.2,"10th_percentile":144.2,"90th_percentile":192.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":15.58,"10th_percentile":15.58,"90th_percentile":15.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1412","median_amount":37.72,"10th_percentile":35.22,"90th_percentile":38.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"26","median_amount":156.03,"10th_percentile":128.49,"90th_percentile":157.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"14","median_amount":156.91,"10th_percentile":122.83,"90th_percentile":156.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16.81,"10th_percentile":16.81,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"12","median_amount":165.75,"10th_percentile":136.5,"90th_percentile":165.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"223","median_amount":153.6,"10th_percentile":122.88,"90th_percentile":158.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":37.42,"10th_percentile":37.42,"90th_percentile":37.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"709","median_amount":37.73,"10th_percentile":29.34,"90th_percentile":38.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"34","median_amount":30.78,"10th_percentile":29.93,"90th_percentile":38.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":160.23,"10th_percentile":159.56,"90th_percentile":329.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.84,"10th_percentile":64.84,"90th_percentile":64.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":287.62,"10th_percentile":127.35,"90th_percentile":891.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":656.49,"10th_percentile":216.0,"90th_percentile":2900.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":648.0,"10th_percentile":216.0,"90th_percentile":1728.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":243.8,"10th_percentile":146.28,"90th_percentile":341.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":645.55,"10th_percentile":645.55,"90th_percentile":645.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1504.8,"10th_percentile":755.31,"90th_percentile":1510.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1836.12,"10th_percentile":659.16,"90th_percentile":2966.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2852.82,"10th_percentile":2852.82,"90th_percentile":2852.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":518.7,"10th_percentile":127.65,"90th_percentile":1222.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2697.87,"10th_percentile":2697.87,"90th_percentile":2697.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":438.84,"10th_percentile":438.84,"90th_percentile":438.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"238","median_amount":638.25,"10th_percentile":127.65,"90th_percentile":1318.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"21","median_amount":938.28,"10th_percentile":302.17,"90th_percentile":1876.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2830.77,"10th_percentile":2830.77,"90th_percentile":3774.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"96","median_amount":1231.56,"10th_percentile":300.46,"90th_percentile":3694.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":778.08,"10th_percentile":778.08,"90th_percentile":778.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"126","median_amount":509.44,"10th_percentile":127.36,"90th_percentile":1278.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Resuscitation and Cardioversion","code_information":[{"code":"5781","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":667.89,"10th_percentile":624.02,"90th_percentile":1505.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5056.54,"10th_percentile":2045.02,"90th_percentile":7357.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2684.22,"10th_percentile":2131.73,"90th_percentile":3928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":6392.42,"10th_percentile":6392.42,"90th_percentile":6392.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":618.42,"10th_percentile":618.42,"90th_percentile":618.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1303.52,"10th_percentile":1296.77,"90th_percentile":2383.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6140.38,"10th_percentile":6140.38,"90th_percentile":6140.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5491.61,"10th_percentile":5491.61,"90th_percentile":5491.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":663.59,"10th_percentile":546.26,"90th_percentile":1413.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":2456.69,"10th_percentile":2456.69,"90th_percentile":2456.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"115","median_amount":667.89,"10th_percentile":529.51,"90th_percentile":1222.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5410.59,"10th_percentile":5410.59,"90th_percentile":5410.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5439.99,"10th_percentile":5439.99,"90th_percentile":5439.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":683.13,"10th_percentile":683.13,"90th_percentile":683.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":3755.67,"10th_percentile":1909.51,"90th_percentile":5276.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":378.55,"10th_percentile":331.85,"90th_percentile":414.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"41","median_amount":668.9,"10th_percentile":365.0,"90th_percentile":1225.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":292.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1099.09,"10th_percentile":1099.09,"90th_percentile":1756.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2349.99,"10th_percentile":1467.0,"90th_percentile":2350.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":227.64,"10th_percentile":227.64,"90th_percentile":227.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":986.55,"10th_percentile":986.55,"90th_percentile":986.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":250.0,"10th_percentile":250.0,"90th_percentile":250.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":240.42,"10th_percentile":126.77,"90th_percentile":248.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":1139.4,"10th_percentile":1139.4,"90th_percentile":1139.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":84.83,"10th_percentile":69.0,"90th_percentile":138.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":206.12,"10th_percentile":205.72,"90th_percentile":544.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1393.25,"10th_percentile":1393.25,"90th_percentile":1393.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":540.59,"10th_percentile":540.59,"90th_percentile":540.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6613.22,"10th_percentile":6613.22,"90th_percentile":6613.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"19","median_amount":1077.25,"10th_percentile":328.35,"90th_percentile":2201.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":127.4,"10th_percentile":74.17,"90th_percentile":302.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":165.03,"10th_percentile":165.03,"90th_percentile":165.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Health and Behavior Services","code_information":[{"code":"5821","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7358.1,"10th_percentile":7358.1,"90th_percentile":7358.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2601.34,"10th_percentile":2601.34,"90th_percentile":2601.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Health and Behavior Services","code_information":[{"code":"5822","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":97.88,"10th_percentile":97.88,"90th_percentile":97.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":217.44,"10th_percentile":217.44,"90th_percentile":355.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":931.0,"10th_percentile":352.0,"90th_percentile":2463.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":644.0,"10th_percentile":390.0,"90th_percentile":1027.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":539.0,"10th_percentile":539.0,"90th_percentile":539.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":312.63,"10th_percentile":269.78,"90th_percentile":400.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":293.64,"10th_percentile":293.64,"90th_percentile":416.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":671.81,"10th_percentile":671.81,"90th_percentile":671.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":87.04,"10th_percentile":87.04,"90th_percentile":87.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":434.9,"10th_percentile":434.9,"90th_percentile":434.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":372.76,"10th_percentile":286.89,"90th_percentile":502.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":491.39,"10th_percentile":491.39,"90th_percentile":545.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":263.44,"10th_percentile":263.44,"90th_percentile":489.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":61.16,"10th_percentile":61.16,"90th_percentile":61.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":28.0,"10th_percentile":28.0,"90th_percentile":28.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Health and Behavior Services","code_information":[{"code":"5823","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"104","median_amount":64.21,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"117","median_amount":163.31,"10th_percentile":123.31,"90th_percentile":489.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"255","median_amount":289.0,"10th_percentile":125.6,"90th_percentile":573.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":191.0,"10th_percentile":157.0,"90th_percentile":696.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"273","median_amount":64.21,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"31","median_amount":158.53,"10th_percentile":120.35,"90th_percentile":385.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":166.83,"10th_percentile":166.83,"90th_percentile":427.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":130.21,"10th_percentile":93.48,"90th_percentile":209.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"41","median_amount":170.85,"10th_percentile":103.19,"90th_percentile":324.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":120.84,"10th_percentile":64.21,"90th_percentile":201.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":155.07,"10th_percentile":136.22,"90th_percentile":310.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"127","median_amount":161.44,"10th_percentile":116.8,"90th_percentile":331.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"57","median_amount":130.94,"10th_percentile":103.41,"90th_percentile":284.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"113","median_amount":188.0,"10th_percentile":71.77,"90th_percentile":419.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"65","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":241.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":494.57,"10th_percentile":147.54,"90th_percentile":649.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":181.26,"10th_percentile":120.84,"90th_percentile":196.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":124.05,"10th_percentile":124.05,"90th_percentile":124.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"51","median_amount":349.74,"10th_percentile":158.4,"90th_percentile":699.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.21,"10th_percentile":64.21,"90th_percentile":151.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"440","median_amount":162.51,"10th_percentile":136.22,"90th_percentile":418.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"340","median_amount":197.68,"10th_percentile":102.37,"90th_percentile":354.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"104","median_amount":167.56,"10th_percentile":111.47,"90th_percentile":382.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":279.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":268.5,"10th_percentile":268.5,"90th_percentile":268.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"40","median_amount":143.25,"10th_percentile":83.4,"90th_percentile":311.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":222.0,"10th_percentile":220.5,"90th_percentile":580.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":143.25,"10th_percentile":57.33,"90th_percentile":249.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":116.85,"10th_percentile":116.85,"90th_percentile":348.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":113.43,"10th_percentile":75.67,"90th_percentile":120.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":126.58,"10th_percentile":29.36,"90th_percentile":158.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"115","median_amount":272.44,"10th_percentile":153.86,"90th_percentile":433.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":276.3,"10th_percentile":276.3,"90th_percentile":378.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":213.71,"10th_percentile":113.35,"90th_percentile":438.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Covid-19 Vaccine Administration","code_information":[{"code":"9398","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":434.01,"10th_percentile":434.01,"90th_percentile":434.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, labetalol hcl, 5mg","code_information":[{"code":"9400","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4.58,"10th_percentile":4.58,"90th_percentile":4.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Platelet pheres leukoreduced","code_information":[{"code":"9501","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":953.45,"10th_percentile":953.45,"90th_percentile":953.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3153.06,"10th_percentile":3153.06,"90th_percentile":3153.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"RBC leukocytes reduced","code_information":[{"code":"9512","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3756.4,"10th_percentile":3756.4,"90th_percentile":3756.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"RBC leukoreduced irradiated","code_information":[{"code":"9522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":952.19,"10th_percentile":952.19,"90th_percentile":952.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Plate pheres leukoredu irrad","code_information":[{"code":"9530","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":1128.02,"10th_percentile":1063.16,"90th_percentile":1436.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":1128.42,"10th_percentile":1075.43,"90th_percentile":1393.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1202.45,"10th_percentile":1186.7,"90th_percentile":2030.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2296.26,"10th_percentile":2296.26,"90th_percentile":2296.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"157","median_amount":61.85,"10th_percentile":53.56,"90th_percentile":90.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"328","median_amount":128.56,"10th_percentile":102.84,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"218","median_amount":164.09,"10th_percentile":88.0,"90th_percentile":255.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"542","median_amount":76.0,"10th_percentile":69.89,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":76.0,"10th_percentile":76.0,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":61.36,"10th_percentile":51.28,"90th_percentile":73.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"90","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":116.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":231.12,"10th_percentile":231.12,"90th_percentile":231.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"11","median_amount":102.09,"10th_percentile":93.79,"90th_percentile":224.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":102.09,"10th_percentile":102.09,"90th_percentile":102.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":64.95,"10th_percentile":64.43,"90th_percentile":73.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"21","median_amount":159.8,"10th_percentile":80.7,"90th_percentile":274.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":67.11,"10th_percentile":65.81,"90th_percentile":90.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"52","median_amount":130.35,"10th_percentile":120.54,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"66","median_amount":255.38,"10th_percentile":239.69,"90th_percentile":256.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"90","median_amount":139.87,"10th_percentile":91.5,"90th_percentile":240.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"32","median_amount":91.5,"10th_percentile":74.4,"90th_percentile":240.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"372","median_amount":130.35,"10th_percentile":113.0,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"48","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":88.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":121.19,"10th_percentile":102.84,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":112.9,"10th_percentile":112.9,"90th_percentile":112.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"33","median_amount":229.68,"10th_percentile":98.31,"90th_percentile":281.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":159.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":67.18,"10th_percentile":53.56,"90th_percentile":87.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1946","median_amount":130.35,"10th_percentile":120.54,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"263","median_amount":152.5,"10th_percentile":71.84,"90th_percentile":212.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"102","median_amount":187.44,"10th_percentile":80.23,"90th_percentile":229.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"50","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":116.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"33","median_amount":203.25,"10th_percentile":84.75,"90th_percentile":242.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"689","median_amount":188.35,"10th_percentile":130.66,"90th_percentile":224.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"14","median_amount":84.75,"10th_percentile":72.32,"90th_percentile":92.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":65.53,"10th_percentile":53.56,"90th_percentile":103.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":68.46,"10th_percentile":39.36,"90th_percentile":108.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.56,"10th_percentile":128.56,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"988","median_amount":130.35,"10th_percentile":104.28,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"152","median_amount":120.54,"10th_percentile":110.74,"90th_percentile":132.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"23","median_amount":268.2,"10th_percentile":237.6,"90th_percentile":290.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"11","median_amount":195.66,"10th_percentile":153.12,"90th_percentile":233.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"54","median_amount":92.13,"10th_percentile":53.56,"90th_percentile":212.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"331","median_amount":130.35,"10th_percentile":104.28,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"101","median_amount":311.26,"10th_percentile":91.64,"90th_percentile":920.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"308","median_amount":91.64,"10th_percentile":20.42,"90th_percentile":266.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":20.42,"10th_percentile":20.42,"90th_percentile":20.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"27","median_amount":61.81,"10th_percentile":59.49,"90th_percentile":137.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":71.27,"10th_percentile":71.27,"90th_percentile":71.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":413.0,"10th_percentile":413.0,"90th_percentile":413.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"16","median_amount":172.09,"10th_percentile":158.73,"90th_percentile":322.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":388.04,"10th_percentile":388.04,"90th_percentile":388.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.0,"10th_percentile":10.53,"90th_percentile":121.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"22","median_amount":122.4,"10th_percentile":33.91,"90th_percentile":339.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":125.11,"10th_percentile":76.85,"90th_percentile":245.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":153.44,"10th_percentile":128.56,"90th_percentile":481.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"32","median_amount":255.38,"10th_percentile":239.69,"90th_percentile":256.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"40","median_amount":318.41,"10th_percentile":182.28,"90th_percentile":650.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":318.41,"10th_percentile":201.47,"90th_percentile":1381.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"544","median_amount":130.35,"10th_percentile":121.71,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":87.5,"10th_percentile":10.03,"90th_percentile":395.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":104.28,"10th_percentile":102.84,"90th_percentile":208.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9.71,"10th_percentile":9.71,"90th_percentile":9.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"28","median_amount":213.15,"10th_percentile":70.0,"90th_percentile":621.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":1.49,"10th_percentile":1.49,"90th_percentile":1.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":76.14,"10th_percentile":10.53,"90th_percentile":137.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2280","median_amount":130.35,"10th_percentile":128.56,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"124","median_amount":302.17,"10th_percentile":153.95,"90th_percentile":964.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"67","median_amount":303.88,"10th_percentile":163.3,"90th_percentile":741.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":57.99,"10th_percentile":57.99,"90th_percentile":115.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"30","median_amount":188.5,"10th_percentile":109.81,"90th_percentile":439.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"543","median_amount":9.71,"10th_percentile":4.29,"90th_percentile":94.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"17","median_amount":32.6,"10th_percentile":17.14,"90th_percentile":103.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":80.15,"10th_percentile":27.5,"90th_percentile":175.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":18.43,"10th_percentile":16.52,"90th_percentile":127.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.56,"10th_percentile":128.56,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1331","median_amount":130.35,"10th_percentile":109.63,"90th_percentile":292.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"67","median_amount":132.96,"10th_percentile":124.14,"90th_percentile":496.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":311.4,"10th_percentile":311.4,"90th_percentile":311.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":176.89,"10th_percentile":32.92,"90th_percentile":176.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":307.5,"10th_percentile":307.5,"90th_percentile":1968.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"264","median_amount":156.8,"10th_percentile":62.66,"90th_percentile":396.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"539","median_amount":140.95,"10th_percentile":66.44,"90th_percentile":380.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"557","median_amount":770.0,"10th_percentile":249.0,"90th_percentile":1950.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1231","median_amount":596.0,"10th_percentile":224.8,"90th_percentile":1788.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":316.0,"10th_percentile":316.0,"90th_percentile":316.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"231","median_amount":173.48,"10th_percentile":65.79,"90th_percentile":395.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":65.79,"10th_percentile":65.79,"90th_percentile":65.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":432.43,"10th_percentile":432.43,"90th_percentile":432.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"29","median_amount":461.0,"10th_percentile":264.0,"90th_percentile":1496.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":118.32,"10th_percentile":65.79,"90th_percentile":283.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"115","median_amount":671.5,"10th_percentile":224.4,"90th_percentile":2105.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"115","median_amount":155.78,"10th_percentile":59.16,"90th_percentile":390.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"63","median_amount":104.92,"10th_percentile":48.2,"90th_percentile":256.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":182.65,"10th_percentile":140.31,"90th_percentile":269.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"296","median_amount":604.83,"10th_percentile":182.0,"90th_percentile":1728.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"43","median_amount":530.93,"10th_percentile":182.0,"90th_percentile":1928.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"403","median_amount":137.15,"10th_percentile":54.03,"90th_percentile":352.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"102","median_amount":145.1,"10th_percentile":56.91,"90th_percentile":325.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":145.69,"10th_percentile":64.55,"90th_percentile":210.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":185.49,"10th_percentile":185.49,"90th_percentile":185.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"11","median_amount":82.13,"10th_percentile":41.06,"90th_percentile":191.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"80","median_amount":617.8,"10th_percentile":185.4,"90th_percentile":1579.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":267.2,"10th_percentile":267.2,"90th_percentile":380.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"200","median_amount":137.5,"10th_percentile":65.79,"90th_percentile":357.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2996","median_amount":142.02,"10th_percentile":57.12,"90th_percentile":402.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"524","median_amount":683.22,"10th_percentile":263.0,"90th_percentile":1708.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"217","median_amount":759.44,"10th_percentile":366.88,"90th_percentile":2278.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"55","median_amount":105.4,"10th_percentile":51.87,"90th_percentile":266.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1522.5,"10th_percentile":890.25,"90th_percentile":2021.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"79","median_amount":782.78,"10th_percentile":258.2,"90th_percentile":2067.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"3073","median_amount":574.0,"10th_percentile":229.6,"90th_percentile":1704.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":284.0,"10th_percentile":284.0,"90th_percentile":284.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"655","median_amount":139.34,"10th_percentile":59.16,"90th_percentile":317.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":62.66,"10th_percentile":62.66,"90th_percentile":62.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.67,"10th_percentile":60.42,"90th_percentile":259.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1836","median_amount":148.84,"10th_percentile":63.83,"90th_percentile":416.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"215","median_amount":117.38,"10th_percentile":54.83,"90th_percentile":286.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"733","median_amount":926.64,"10th_percentile":308.16,"90th_percentile":2153.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"14","median_amount":1328.02,"10th_percentile":362.6,"90th_percentile":1813.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"222","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"310","median_amount":303.65,"10th_percentile":225.3,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"822","median_amount":225.3,"10th_percentile":225.3,"90th_percentile":237.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":303.65,"10th_percentile":303.65,"90th_percentile":303.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"39","median_amount":30.51,"10th_percentile":30.51,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":356.9,"10th_percentile":356.9,"90th_percentile":356.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"18","median_amount":356.9,"10th_percentile":338.98,"90th_percentile":356.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":338.98,"10th_percentile":338.98,"90th_percentile":338.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":30.52,"10th_percentile":30.52,"90th_percentile":30.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"68","median_amount":365.5,"10th_percentile":365.5,"90th_percentile":365.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":151.14,"10th_percentile":151.14,"90th_percentile":154.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":207.04,"10th_percentile":107.83,"90th_percentile":208.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"190","median_amount":319.91,"10th_percentile":319.91,"90th_percentile":319.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"36","median_amount":319.91,"10th_percentile":307.68,"90th_percentile":319.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"240","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":182.17,"10th_percentile":182.17,"90th_percentile":182.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"54","median_amount":374.1,"10th_percentile":374.1,"90th_percentile":374.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":430.0,"10th_percentile":430.0,"90th_percentile":430.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"53","median_amount":30.51,"10th_percentile":30.51,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1846","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"295","median_amount":244.01,"10th_percentile":236.9,"90th_percentile":244.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"93","median_amount":262.19,"10th_percentile":253.33,"90th_percentile":262.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"48","median_amount":322.5,"10th_percentile":322.5,"90th_percentile":344.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1791","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"106","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":105.68,"10th_percentile":105.68,"90th_percentile":105.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":108.76,"10th_percentile":108.76,"90th_percentile":108.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"855","median_amount":105.68,"10th_percentile":105.67,"90th_percentile":108.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"53","median_amount":107.79,"10th_percentile":107.79,"90th_percentile":110.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"14","median_amount":250.64,"10th_percentile":242.16,"90th_percentile":250.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Durable Medical Equipment","code_information":[{"code":"N805","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":100.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":526.44,"10th_percentile":526.44,"90th_percentile":526.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":468.54,"10th_percentile":468.54,"90th_percentile":468.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":100.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":499.57,"10th_percentile":499.57,"90th_percentile":499.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":530.7,"10th_percentile":530.7,"90th_percentile":530.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":491.78,"10th_percentile":393.42,"90th_percentile":506.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":636.84,"10th_percentile":636.84,"90th_percentile":636.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":102.79,"10th_percentile":102.79,"90th_percentile":102.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"105","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"84","median_amount":30.39,"10th_percentile":29.36,"90th_percentile":60.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"54","median_amount":52.14,"10th_percentile":41.71,"90th_percentile":94.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"220","median_amount":38.28,"10th_percentile":34.8,"90th_percentile":104.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":52.14,"10th_percentile":52.14,"90th_percentile":52.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5.11,"10th_percentile":5.11,"90th_percentile":5.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"129","median_amount":5.11,"10th_percentile":5.11,"90th_percentile":10.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":94.45,"10th_percentile":54.78,"90th_percentile":99.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5.85,"10th_percentile":5.12,"90th_percentile":83.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"12","median_amount":102.0,"10th_percentile":56.1,"90th_percentile":112.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":8.78,"10th_percentile":5.85,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":30.39,"10th_percentile":28.07,"90th_percentile":30.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"29","median_amount":49.1,"10th_percentile":44.64,"90th_percentile":89.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"11","median_amount":89.28,"10th_percentile":47.23,"90th_percentile":89.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"37","median_amount":31.01,"10th_percentile":24.31,"90th_percentile":62.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":29.36,"10th_percentile":29.36,"90th_percentile":29.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":9.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":48.63,"10th_percentile":24.31,"90th_percentile":62.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":104.4,"10th_percentile":104.4,"90th_percentile":104.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":6.14,"10th_percentile":5.11,"90th_percentile":6.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"192","median_amount":48.62,"10th_percentile":29.36,"90th_percentile":132.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"91","median_amount":46.6,"10th_percentile":42.36,"90th_percentile":85.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"40","median_amount":42.6,"10th_percentile":42.6,"90th_percentile":93.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"24","median_amount":5.85,"10th_percentile":4.87,"90th_percentile":110.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":47.23,"10th_percentile":47.23,"90th_percentile":47.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"11","median_amount":72.0,"10th_percentile":49.5,"90th_percentile":90.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"25","median_amount":241.4,"10th_percentile":45.87,"90th_percentile":574.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.69,"10th_percentile":22.69,"90th_percentile":22.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.69,"10th_percentile":22.69,"90th_percentile":45.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":60.78,"10th_percentile":30.39,"90th_percentile":179.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"61","median_amount":31.0,"10th_percentile":24.79,"90th_percentile":99.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":54.0,"10th_percentile":54.0,"90th_percentile":279.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":47.65,"10th_percentile":47.65,"90th_percentile":47.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.73,"10th_percentile":29.73,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":115.49,"10th_percentile":95.56,"90th_percentile":125.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"23","median_amount":303.65,"10th_percentile":225.3,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"47","median_amount":225.3,"10th_percentile":225.3,"90th_percentile":334.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":338.3,"10th_percentile":256.76,"90th_percentile":338.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"13","median_amount":183.48,"10th_percentile":125.1,"90th_percentile":184.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"13","median_amount":186.0,"10th_percentile":186.0,"90th_percentile":186.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":186.0,"10th_percentile":186.0,"90th_percentile":186.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":93.84,"10th_percentile":74.92,"90th_percentile":122.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":63.51,"10th_percentile":63.51,"90th_percentile":63.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"1 through 10","median_amount":662.07,"10th_percentile":662.07,"90th_percentile":662.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":30.51,"10th_percentile":14.23,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"106","median_amount":100.29,"10th_percentile":93.65,"90th_percentile":123.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":244.01,"10th_percentile":183.81,"90th_percentile":244.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":262.19,"10th_percentile":262.19,"90th_percentile":262.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.73,"10th_percentile":29.73,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":318.4,"10th_percentile":318.4,"90th_percentile":318.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"87","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":29.06,"10th_percentile":13.55,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"54","median_amount":99.71,"10th_percentile":93.65,"90th_percentile":122.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":101.69,"10th_percentile":95.52,"90th_percentile":125.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":60.42,"10th_percentile":53.7,"90th_percentile":60.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":129.36,"10th_percentile":91.15,"90th_percentile":131.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"22","median_amount":212.8,"10th_percentile":110.01,"90th_percentile":280.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"24","median_amount":220.0,"10th_percentile":220.0,"90th_percentile":233.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":220.0,"10th_percentile":220.0,"90th_percentile":698.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":60.42,"10th_percentile":53.7,"90th_percentile":120.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":232.4,"10th_percentile":232.4,"90th_percentile":232.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":177.65,"10th_percentile":177.65,"90th_percentile":177.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":200.12,"10th_percentile":200.12,"90th_percentile":233.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":176.02,"10th_percentile":176.02,"90th_percentile":176.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":130.35,"10th_percentile":42.15,"90th_percentile":192.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.31,"10th_percentile":24.31,"90th_percentile":24.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"107","median_amount":130.35,"10th_percentile":121.71,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":187.8,"10th_percentile":174.92,"90th_percentile":221.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":205.19,"10th_percentile":205.19,"90th_percentile":205.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2092.7,"10th_percentile":2092.7,"90th_percentile":2092.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1.83,"10th_percentile":1.83,"90th_percentile":1.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":323.25,"10th_percentile":323.25,"90th_percentile":323.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":86.25,"10th_percentile":86.25,"90th_percentile":86.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":130.65,"10th_percentile":130.65,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":225.96,"10th_percentile":225.96,"90th_percentile":429.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(Wi3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Doc","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 87] [OP Surgery  (%BC): 87] [Observation (%BC): 87] [Emergency Department (%BC): 87] [Occupational Therapy (%BC): 87] [Physical Therapy (%BC): 87] [Respiratory Services/Therapy  (%BC): 87] [Speech Therapy (%BC): 87] [All Other OP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 75] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2060.99,"10th_percentile":2060.99,"90th_percentile":2060.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":707.48,"10th_percentile":707.48,"90th_percentile":707.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone marrow transplant","code_information":[{"code":"009","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hyphema","code_information":[{"code":"043","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections","code_information":[{"code":"044","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological eye disorders","code_information":[{"code":"045","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age >17 w CC","code_information":[{"code":"046","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age >17 w/o CC","code_information":[{"code":"047","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age 0-17","code_information":[{"code":"048","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures","code_information":[{"code":"049","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sialoadenectomy","code_information":[{"code":"050","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures Except Sialoadenectomy","code_information":[{"code":"051","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Cc","code_information":[{"code":"078","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4895.18,"10th_percentile":4895.18,"90th_percentile":4895.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.88,"10th_percentile":282.88,"90th_percentile":282.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy Without Cc/Mcc","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","code_information":[{"code":"104","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","code_information":[{"code":"105","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass w PTCA","code_information":[{"code":"106","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"107","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures","code_information":[{"code":"108","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"109","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Cardiovascular Procedures w CC","code_information":[{"code":"110","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Cardiovascular Procedures w/o CC","code_information":[{"code":"111","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"112","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement","code_information":[{"code":"118","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein ligation & stripping","code_information":[{"code":"119","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other circulatory system O.R. procedures","code_information":[{"code":"120","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute & Subacute Endocarditis","code_information":[{"code":"126","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure & Shock","code_information":[{"code":"127","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis","code_information":[{"code":"128","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures W Cc/Mcc Or Major Device","code_information":[{"code":"129","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures W/O Cc/Mcc","code_information":[{"code":"130","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial/Facial Procedures W Cc/Mcc","code_information":[{"code":"131","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial/Facial Procedures W/O Cc/Mcc","code_information":[{"code":"132","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","code_information":[{"code":"133","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","code_information":[{"code":"134","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","code_information":[{"code":"160","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal & Femoral Hernia Procedures Age >17 w CC","code_information":[{"code":"161","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","code_information":[{"code":"162","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures w/o CC","code_information":[{"code":"169","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures w/o CC","code_information":[{"code":"171","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"G.I. hemorrhage w CC","code_information":[{"code":"174","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip & Femur Procedures Except Major Joint Age >17 w CC","code_information":[{"code":"210","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","code_information":[{"code":"211","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"214","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","code_information":[{"code":"222","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","code_information":[{"code":"223","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","code_information":[{"code":"224","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","code_information":[{"code":"225","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","code_information":[{"code":"226","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","code_information":[{"code":"227","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other cardiothoracic procedures w/o CC/MCC","code_information":[{"code":"230","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major cardiovasc procedures w MCC","code_information":[{"code":"237","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major cardiovasc procedures w/o MCC","code_information":[{"code":"238","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"246","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","code_information":[{"code":"247","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"248","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","code_information":[{"code":"249","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis With Cc/Mcc","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis Without Cc/Mcc","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Mcc","code_information":[{"code":"338","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Cc","code_information":[{"code":"339","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"340","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Mcc","code_information":[{"code":"341","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Cc","code_information":[{"code":"342","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"343","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopy & Incisional Tubal Interruption","code_information":[{"code":"361","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endoscopic Tubal Interruption","code_information":[{"code":"362","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization & Radio-Implant, for Malignancy","code_information":[{"code":"363","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization Except for Malignancy","code_information":[{"code":"364","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures","code_information":[{"code":"365","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, female reproductive system w CC","code_information":[{"code":"366","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System w/o CC","code_information":[{"code":"367","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Age 0-17","code_information":[{"code":"396","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"400","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & non-acute leukemia w other O.R. proc w CC","code_information":[{"code":"401","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & non-acute leukemia w CC","code_information":[{"code":"403","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & Non-Acute Leukemia w/o CC","code_information":[{"code":"404","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Childhood Mental Disorders","code_information":[{"code":"431","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning & toxic Effects of Drugs Age >17 w CC","code_information":[{"code":"449","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications of treatment w CC","code_information":[{"code":"452","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Mcc","code_information":[{"code":"453","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Cc","code_information":[{"code":"454","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"459","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"460","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","code_information":[{"code":"484","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","code_information":[{"code":"490","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back & neck proc exc spinal fusion w/o CC/MCC","code_information":[{"code":"491","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Arthroscopy","code_information":[{"code":"509","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","code_information":[{"code":"523","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient ischemia","code_information":[{"code":"524","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other heart assist system implant","code_information":[{"code":"525","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"526","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"527","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Proc w Pdx Hemorrhage","code_information":[{"code":"528","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular shunt procedures w CC","code_information":[{"code":"529","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures w/o CC","code_information":[{"code":"530","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures w CC","code_information":[{"code":"531","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures w/o CC","code_information":[{"code":"532","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","code_information":[{"code":"567","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","code_information":[{"code":"568","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small & Large Bowel Procedures w CC w Major Gi Dx","code_information":[{"code":"569","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Admit For Renal Dialysis","code_information":[{"code":"685","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones W Esw Lithotripsy W Cc/Mcc","code_information":[{"code":"691","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","code_information":[{"code":"692","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section W Cc/Mcc","code_information":[{"code":"765","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section W/O Cc/Mcc","code_information":[{"code":"766","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W Sterilization &/Or D&C","code_information":[{"code":"767","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W Complicating Diagnoses","code_information":[{"code":"774","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W/O Complicating Diagnoses","code_information":[{"code":"775","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ectopic Pregnancy","code_information":[{"code":"777","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Threatened Abortion","code_information":[{"code":"778","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"False Labor","code_information":[{"code":"780","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses W Medical Complications","code_information":[{"code":"781","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses W/O Medical Complications","code_information":[{"code":"782","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","code_information":[{"code":"984","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","code_information":[{"code":"985","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","code_information":[{"code":"986","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Principal Diagnosis Invalid As Discharge Diagnosis","code_information":[{"code":"998","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ungroupable","code_information":[{"code":"999","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Access Ppo","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Preferred / Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(Wi1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(Wi2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Faboh","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 87] [All Other IP (%BC): 87]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Phcs Primary Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 85] [All Other IP (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":300.0,"10th_percentile":300.0,"90th_percentile":300.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Network Health Plan","plan_name":"Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wps Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rem mlt day uroflow setup","code_information":[{"code":"0811T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr impl ivc snr set-up","code_information":[{"code":"0982T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr s-scl eeg sys setup","code_information":[{"code":"1008T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam new patient","code_information":[{"code":"92002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam new patient","code_information":[{"code":"92004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam establish patient","code_information":[{"code":"92012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam&tx estab pt 1/>vst","code_information":[{"code":"92014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Glucose monitoring cont","code_information":[{"code":"95250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr 1st setup&edu","code_information":[{"code":"98975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"Doc","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"Molina","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr physiol param 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